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General NPI Number Information
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NPI Number | 1073070736
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Entity Type | Organization
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Legal Business Name | BLUE GOAT MANAGEMENT LLC
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Dates
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Enumeration Date | 02/28/2019
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Last Update Date | 03/06/2019
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Provider Practice Location Address
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Address Line | 401 W TEXAS AVE
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City | BAYTOWN
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State | TX
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Zip | 77520-4751
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Country | US
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Telephone | 832-526-4920
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Fax |
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Provider Business Mailing Address
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Address Line | 401 W TEXAS AVE
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City | BAYTOWN
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State | TX
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Zip | 77520-4751
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | MANAGER
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Name | MICHELLE FORRESTER
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Credential |
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Telephone | 973-740-0023
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 174400000X
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Taxonomy Name | Specialist
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 2084P0800X
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Taxonomy Name | Psychiatry Physician
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License Number |
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License Number State |
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