Healthcare Provider Details

I. General information

NPI: 1518536309
Provider Name (Legal Business Name): BLUEBONNET TRAILS COMMUNITY MHMR CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/24/2021
Last Update Date: 08/25/2023
Certification Date: 08/25/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

750 W TRAVIS ST
LA GRANGE TX
78945-2522
US

IV. Provider business mailing address

1009 N GEORGETOWN ST
ROUND ROCK TX
78664-3289
US

V. Phone/Fax

Practice location:
  • Phone: 512-255-1720
  • Fax: 512-244-8401
Mailing address:
  • Phone: 512-255-1720
  • Fax: 512-244-8401

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QR1300X
TaxonomyRural Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: ANDREA RICHARDSON
Title or Position: EXECUTIVE DIRECTOR
Credential:
Phone: 512-244-8305