Healthcare Provider Details

I. General information

NPI: 1346377579
Provider Name (Legal Business Name): AUSTIN TRAVIS COUNTY MHMR CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/27/2007
Last Update Date: 09/21/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5225 N LAMAR BLVD
AUSTIN TX
78751-1820
US

IV. Provider business mailing address

PO BOX 3548
AUSTIN TX
78764-3548
US

V. Phone/Fax

Practice location:
  • Phone: 512-483-5800
  • Fax: 512-483-5800
Mailing address:
  • Phone: 512-445-7787
  • Fax: 512-440-4059

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TM1800X
TaxonomyIntellectual & Developmental Disabilities Psychologist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State

VIII. Authorized Official

Name: DR. JAMES RUSSEL VAN NORMAN
Title or Position: MEDICAL DIRECTOR
Credential: M.D.
Phone: 512-440-4021