Healthcare Provider Details

I. General information

NPI: 1114769130
Provider Name (Legal Business Name): THAT 1 HOME
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/10/2024
Last Update Date: 06/19/2024
Certification Date: 06/19/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

19126 MOSSY HEDGE LN
KATY TX
77449-4133
US

IV. Provider business mailing address

19126 MOSSY HEDGE LN
KATY TX
77449-4133
US

V. Phone/Fax

Practice location:
  • Phone: 832-785-4089
  • Fax:
Mailing address:
  • Phone: 832-785-4089
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WA2000X
TaxonomyAdministrator Registered Nurse
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code364SL0600X
TaxonomyLong-Term Care Clinical Nurse Specialist
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number
License Number State
# 5
Primary TaxonomyY
Taxonomy Code320900000X
TaxonomyIntellectual and/or Developmental Disabilities Community Based Residential Treatment Facility
License Number
License Number State

VIII. Authorized Official

Name: MRS. DEANDRA JOHNSON-EGESI
Title or Position: PROGRAM MANAGER
Credential: RN
Phone: 832-785-4089