Provider Demographics
NPI:1770812554
Name:MINOLA'S PLACE OF TEXAS , INC
Entity type:Organization
Organization Name:MINOLA'S PLACE OF TEXAS , INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:ROZELLA
Authorized Official - Middle Name:
Authorized Official - Last Name:GRAY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:281-251-7696
Mailing Address - Street 1:17940 COUNTRY WALK
Mailing Address - Street 2:
Mailing Address - City:SPRING
Mailing Address - State:TX
Mailing Address - Zip Code:77379
Mailing Address - Country:US
Mailing Address - Phone:281-251-7696
Mailing Address - Fax:
Practice Address - Street 1:17940 COUNTRY WALK DR
Practice Address - Street 2:
Practice Address - City:SPRING
Practice Address - State:TX
Practice Address - Zip Code:77379-6169
Practice Address - Country:US
Practice Address - Phone:281-251-7696
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-12-08
Last Update Date:2009-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX50907104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes104100000XBehavioral Health & Social Service ProvidersSocial WorkerGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1275711947Medicaid