Provider Demographics
NPI:1770036824
Name:LW BEHAVIORAL HEALTH SERVICES
Entity Type:Organization
Organization Name:LW BEHAVIORAL HEALTH SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:LAURA
Authorized Official - Middle Name:CAIN
Authorized Official - Last Name:WAHLSTROM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:612-743-6889
Mailing Address - Street 1:6005 GARDENRIDGE HOLW
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78750-8216
Mailing Address - Country:US
Mailing Address - Phone:612-743-6889
Mailing Address - Fax:
Practice Address - Street 1:6005 GARDENRIDGE HOLW
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78750-8216
Practice Address - Country:US
Practice Address - Phone:612-743-6889
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-07-25
Last Update Date:2016-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX37127103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Multi-Specialty