Healthcare Provider Details

I. General information

NPI: 1023150877
Provider Name (Legal Business Name): BLUEBONNET TRAILS COMMUNITY MHMR CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/12/2007
Last Update Date: 08/28/2023
Certification Date: 08/28/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1009 N GEORGETOWN ST
ROUND ROCK TX
78664-3289
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: 512-244-8371
Mailing address:
  • Phone: 512-255-1720
  • Fax: 512-244-8371

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WP0808X
TaxonomyPsychiatric/Mental Health Registered Nurse
License NumberNO LICENSE
License Number StateTX
# 2
Primary TaxonomyN
Taxonomy Code163WP0809X
TaxonomyAdult Psychiatric/Mental Health Registered Nurse
License NumberNO LICESE
License Number StateTX
# 3
Primary TaxonomyN
Taxonomy Code164X00000X
TaxonomyLicensed Vocational Nurse
License NumberNO LICENSE
License Number StateTX
# 4
Primary TaxonomyN
Taxonomy Code171R00000X
TaxonomyInterpreter
License NumberNO LICENSE
License Number StateTX
# 5
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberNO LICENSE
License Number StateTX
# 6
Primary TaxonomyN
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License NumberNO LICENSE
License Number StateTX
# 7
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberNO LICENSE
License Number StateTX
# 8
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License NumberNO LICENSE
License Number StateTX

VIII. Authorized Official

Name: MS. NORALISA WILLIAMS
Title or Position: CREDENTIALING COORDINATOR
Credential:
Phone: 512-244-8374