Healthcare Provider Details

I. General information

NPI: 1972053403
Provider Name (Legal Business Name): OPEN ROADS BEHAVIORAL HEALTH PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/07/2016
Last Update Date: 10/07/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17751 PARK VALLEY DR
ROUND ROCK TX
78681-3592
US

IV. Provider business mailing address

5808 LOOKOUT MOUNTAIN DR
AUSTIN TX
78731-3618
US

V. Phone/Fax

Practice location:
  • Phone: 512-218-6000
  • Fax:
Mailing address:
  • Phone:
  • Fax: 866-869-8828

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number33043
License Number StateTX

VIII. Authorized Official

Name: MRS. JAIME NELSON
Title or Position: MBR
Credential: NP
Phone: 512-373-6280