Provider Demographics
NPI:1740321686
Name:BROOKHAVEN YOUTH RANCH, INC.
Entity type:Organization
Organization Name:BROOKHAVEN YOUTH RANCH, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:BILL
Authorized Official - Middle Name:
Authorized Official - Last Name:GHOLSON
Authorized Official - Suffix:
Authorized Official - Credentials:MSW
Authorized Official - Phone:254-829-1893
Mailing Address - Street 1:5467 ROGERS HILL RD
Mailing Address - Street 2:
Mailing Address - City:WEST
Mailing Address - State:TX
Mailing Address - Zip Code:76691-2415
Mailing Address - Country:US
Mailing Address - Phone:254-829-1893
Mailing Address - Fax:254-829-1469
Practice Address - Street 1:5467 ROGERS HILL RD
Practice Address - Street 2:
Practice Address - City:WEST
Practice Address - State:TX
Practice Address - Zip Code:76691-2415
Practice Address - Country:US
Practice Address - Phone:254-829-1893
Practice Address - Fax:254-829-1469
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-12
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX236482322D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes322D00000XResidential Treatment FacilitiesResidential Treatment Facility, Emotionally Disturbed Children