Provider Demographics
NPI:1760935720
Name:MHMR AUTHORITY OF BRAZOS VALLEY
Entity Type:Organization
Organization Name:MHMR AUTHORITY OF BRAZOS VALLEY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR ADMINISTRATIVE SERVICES
Authorized Official - Prefix:
Authorized Official - First Name:KEN
Authorized Official - Middle Name:
Authorized Official - Last Name:DANFORD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:979-822-6467
Mailing Address - Street 1:804 S TEXAS AVE
Mailing Address - Street 2:
Mailing Address - City:BRYAN
Mailing Address - State:TX
Mailing Address - Zip Code:77803-3946
Mailing Address - Country:US
Mailing Address - Phone:979-220-2881
Mailing Address - Fax:979-821-9486
Practice Address - Street 1:804 S TEXAS AVE
Practice Address - Street 2:
Practice Address - City:BRYAN
Practice Address - State:TX
Practice Address - Zip Code:77803-3946
Practice Address - Country:US
Practice Address - Phone:979-220-2881
Practice Address - Fax:979-821-9486
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-07-26
Last Update Date:2016-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX72167101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX72167OtherTEXAS STATE LICENSE