Healthcare Provider Details

I. General information

NPI: 1710364153
Provider Name (Legal Business Name): MENTAL HEALTH MENTAL RETARDATION AUTHORITY BRAZOS VALLEY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/06/2015
Last Update Date: 02/17/2026
Certification Date: 02/17/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1504 S TEXAS AVE
BRYAN TX
77802-1015
US

IV. Provider business mailing address

1504 S TEXAS AVE
BRYAN TX
77802-1015
US

V. Phone/Fax

Practice location:
  • Phone: 979-822-6467
  • Fax: 979-821-9448
Mailing address:
  • Phone: 979-822-6467
  • Fax: 979-821-9448

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MR. BILL KELLY
Title or Position: EXECUTIVE DIRECTOR
Credential:
Phone: 979-822-6467