Provider Demographics
NPI:1952485195
Name:HEART OF TEXAS REGION MENTAL HEALTH MENTAL RETARDATION CENTER
Entity Type:Organization
Organization Name:HEART OF TEXAS REGION MENTAL HEALTH MENTAL RETARDATION CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:DANIEL
Authorized Official - Middle Name:
Authorized Official - Last Name:THOMPSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:254-752-3451
Mailing Address - Street 1:110 S 12TH ST
Mailing Address - Street 2:P O BOX 890
Mailing Address - City:WACO
Mailing Address - State:TX
Mailing Address - Zip Code:76701-1810
Mailing Address - Country:US
Mailing Address - Phone:254-752-3451
Mailing Address - Fax:254-752-7421
Practice Address - Street 1:1105 JEFFERSON AVE
Practice Address - Street 2:
Practice Address - City:WACO
Practice Address - State:TX
Practice Address - Zip Code:76701-1212
Practice Address - Country:US
Practice Address - Phone:254-752-7889
Practice Address - Fax:254-752-7899
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-24
Last Update Date:2020-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX2007020591261QM0855X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX111409202Medicaid