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General NPI Number Information
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NPI Number | 1427354729
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Entity Type | Organization
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Legal Business Name | MIDCITIES CENTER FOR CHANGE, LLC
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Dates
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Enumeration Date | 02/03/2011
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Last Update Date | 02/03/2011
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Provider Practice Location Address
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Address Line | 610 S INDUSTRIAL BLVD SUITE 307
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City | EULESS
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State | TX
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Zip | 76040-5048
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Country | US
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Telephone | 817-917-2335
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Fax |
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Provider Business Mailing Address
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Address Line | 610 S INDUSTRIAL BLVD SUITE 307
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City | EULESS
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State | TX
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Zip | 76040-5048
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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 | PARTNER
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Name | KEN ALVIN BENNETT JR.
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Credential | LCSW, CART
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Telephone | 817-917-2335
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 251S00000X
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Taxonomy Name | Community/Behavioral Health Agency
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License Number | 65300
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License Number State | TX
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Taxonomy #2
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Taxonomy Code | 251S00000X
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Taxonomy Name | Community/Behavioral Health Agency
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License Number | 50547
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License Number State | TX
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