Healthcare Provider Details

I. General information

NPI: 1124426226
Provider Name (Legal Business Name): BLUEBONNET TRAILS COMMUNITY MHMR CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/05/2014
Last Update Date: 08/28/2023
Certification Date: 08/28/2023
Deactivation Date: 11/29/2021
Reactivation Date: 06/12/2023

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: 512-727-0130
Mailing address:
  • Phone: 512-255-1720
  • Fax: 512-727-0130

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State

VIII. Authorized Official

Name: MR. PETER GALLIMORE
Title or Position: CREDENTIALING COORDINATOR
Credential:
Phone: 512-244-8374