Healthcare Provider Details

I. General information

NPI: 1033744743
Provider Name (Legal Business Name): MEDICAL BEHAVIORAL HOSPITAL OF CLEAR LAKE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/03/2020
Last Update Date: 08/13/2024
Certification Date: 08/13/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16850 BUCCANEER LN
HOUSTON TX
77058-2507
US

IV. Provider business mailing address

112 W JEFFERSON BLVD STE 600
SOUTH BEND IN
46601-1921
US

V. Phone/Fax

Practice location:
  • Phone: 574-277-2630
  • Fax:
Mailing address:
  • Phone: 574-277-2530
  • Fax: 574-277-2635

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code283Q00000X
TaxonomyPsychiatric Hospital
License Number
License Number State

VIII. Authorized Official

Name: CHRISTY KELTNER
Title or Position: CORP BOD
Credential:
Phone: 615-319-6552