MEDICARE: TEXAS PANHANDLE MENTAL HEALTH MENTAL RETARDATION

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QR0405X	Substance Use Disorder Rehabilitation Clinic/Center	3610-3946	TX

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1013362169
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	TEXAS PANHANDLE MENTAL HEALTH MENTAL RETARDATION

Provider Business Mailing Address
First Line	:	901 WALLACE BLVD
Second Line	:
City	:	AMARILLO
State	:	TX
Zip	:	79106-1705
Country	:	US
Telephone Number	:	806-351-3200
Fax Number	:	806-351-3344

Provider Business Practice Location Address
First Line	:	2002 HARDY ST
Second Line	:
City	:	AMARILLO
State	:	TX
Zip	:	79106-2102
Country	:	US
Telephone Number	:	806-351-3200
Fax Number	:	806-351-3344

Authorized Official
Title or Position	:	EXECUTIVE DIRECTOR
Name	:	MELLISA TALLEY
Credential	:
Telephone Number	:	806-351-3206

Provider Enumeration Date	:	04/26/2016
Last Update Date	:	09/29/2020

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