MEDICARE: BLUEBONNET TRAILS COMMUNITY MHMR CENTER

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207Q00000X	Family Medicine Physician

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1215682752
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BLUEBONNET TRAILS COMMUNITY MHMR CENTER

Provider Business Mailing Address
First Line	:	1009 N GEORGETOWN ST
Second Line	:
City	:	ROUND ROCK
State	:	TX
Zip	:	78664-3289
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	750 W TRAVIS ST
Second Line	:
City	:	LA GRANGE
State	:	TX
Zip	:	78945-2522
Country	:	US
Telephone Number	:	979-968-3711
Fax Number	:

Authorized Official
Title or Position	:	EXECUTIVE DIRECTOR
Name	:	ANDREA RICHARDSON
Credential	:
Telephone Number	:	512-244-8305

Provider Enumeration Date	:	02/14/2022
Last Update Date	:	08/25/2023

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Directions to “BLUEBONNET TRAILS COMMUNITY MHMR CENTER ” Practice Location

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