=====================================================
General NPI Number Information
=====================================================
NPI Number | 1932465630
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MEMORIAL BRAIN AND BEHAVIOR CENTER
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/06/2012
-----------------------------------------------------
Last Update Date | 04/06/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 915 GESSNER RD SUITE 550
-----------------------------------------------------
City | HOUSTON
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77024-2527
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 713-461-6262
-----------------------------------------------------
Fax | 713-461-5111
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 915 GESSNER RD SUITE 550
-----------------------------------------------------
City | HOUSTON
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77024-2527
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 713-461-6262
-----------------------------------------------------
Fax | 713-461-5111
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DIRECTOR
-----------------------------------------------------
Name | DR. CARLOS ADALBERTO MAZAS
-----------------------------------------------------
Credential | PH.D.
-----------------------------------------------------
Telephone | 713-461-6262
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103T00000X
-----------------------------------------------------
Taxonomy Name | Psychologist
-----------------------------------------------------
License Number | 35053
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------