Healthcare Provider Details

I. General information

NPI: 1568403574
Provider Name (Legal Business Name): NORTHEAST TEXAS MENTAL HEALTH MENTAL RETARDATION CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/09/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 C OAKLAWN CENTER
TEXARKANA TX
75501-4159
US

IV. Provider business mailing address

PO BOX 5637
TEXARKANA TX
75505-5637
US

V. Phone/Fax

Practice location:
  • Phone: 903-831-7585
  • Fax: 903-831-4823
Mailing address:
  • Phone: 903-831-7585
  • Fax: 903-831-4823

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name: BETSY FREEMAN
Title or Position: ADMINISTRATIVE & FINANCE DIRECTOR
Credential:
Phone: 903-831-3646