Provider Demographics
NPI:1720057904
Name:GULF BEND MHMR CENTER
Entity Type:Organization
Organization Name:GULF BEND MHMR CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:DONALD
Authorized Official - Middle Name:L
Authorized Official - Last Name:POLZIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:361-575-0611
Mailing Address - Street 1:6502 NURSERY DR
Mailing Address - Street 2:SUITE100
Mailing Address - City:VICTORIA
Mailing Address - State:TX
Mailing Address - Zip Code:77904-1178
Mailing Address - Country:US
Mailing Address - Phone:361-575-0611
Mailing Address - Fax:361-575-0626
Practice Address - Street 1:6502 NURSERY DR
Practice Address - Street 2:SUITE100
Practice Address - City:VICTORIA
Practice Address - State:TX
Practice Address - Zip Code:77904-1178
Practice Address - Country:US
Practice Address - Phone:361-575-0611
Practice Address - Fax:361-575-0626
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-17
Last Update Date:2010-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes251B00000XAgenciesCase ManagementGroup - Multi-Specialty
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
No171M00000XOther Service ProvidersCase Manager/Care CoordinatorGroup - Multi-Specialty
No251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX135254402Medicaid