Provider Demographics
NPI:1700919552
Name:MEMORIAL HERMANN
Entity Type:Organization
Organization Name:MEMORIAL HERMANN
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINICAL MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:AVA
Authorized Official - Middle Name:
Authorized Official - Last Name:PROFOTA
Authorized Official - Suffix:
Authorized Official - Credentials:LPC
Authorized Official - Phone:713-868-2908
Mailing Address - Street 1:5518 SANTA CHASE LN
Mailing Address - Street 2:
Mailing Address - City:SUGAR LAND
Mailing Address - State:TX
Mailing Address - Zip Code:77479-5402
Mailing Address - Country:US
Mailing Address - Phone:832-630-3653
Mailing Address - Fax:
Practice Address - Street 1:2000 NORTH LOOP W
Practice Address - Street 2:STE 200
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77018-8124
Practice Address - Country:US
Practice Address - Phone:713-868-2908
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-13
Last Update Date:2008-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX19747273R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes273R00000XHospital UnitsPsychiatric Unit