Healthcare Provider Details

I. General information

NPI: 1770877342
Provider Name (Legal Business Name): SPECTRUM SOCIAL AND RECREATION SERVICES, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/01/2011
Last Update Date: 06/01/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1509 W NORTH LOOP BLVD
AUSTIN TX
78756-2004
US

IV. Provider business mailing address

1509 W NORTH LOOP BLVD
AUSTIN TX
78756-2004
US

V. Phone/Fax

Practice location:
  • Phone: 512-524-5482
  • Fax: 512-524-1177
Mailing address:
  • Phone: 512-524-5482
  • Fax: 512-524-1177

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code252Y00000X
TaxonomyEarly Intervention Provider Agency
License Number
License Number State

VIII. Authorized Official

Name: MRS. SHANNA KEMP
Title or Position: PARTNER / BUSINESS MANAGER
Credential: M.ED.
Phone: 512-524-5482