=====================================================
General NPI Number Information
=====================================================
NPI Number | 1710605506
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | TEXAS IDD SUPPORT SERVICES
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/17/2022
-----------------------------------------------------
Last Update Date | 08/17/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1515 BROADWAY ST
-----------------------------------------------------
City | HOUSTON
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77012-3719
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 713-330-5963
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 24529 COUNTRY OAKS BLVD
-----------------------------------------------------
City | MONTGOMERY
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77316-3898
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 713-330-5963
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO
-----------------------------------------------------
Name | ANASTASIA HALL
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 713-330-5963
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QM0801X
-----------------------------------------------------
Taxonomy Name | Mental Health Clinic/Center (Including Community Mental Health Center)
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------