MEDICARE: DEVEREUX FOUNDATION

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	101YP2500X	Professional Counselor
2	2084P0804X	Child & Adolescent Psychiatry Physician
3	320600000X	Intellectual and/or Developmental Disabilities Residential Treatment Facility	5460	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	:	1609958628
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DEVEREUX FOUNDATION

Provider Business Mailing Address
First Line	:	PO BOX 2666
Second Line	:
City	:	VICTORIA
State	:	TX
Zip	:	77902-2666
Country	:	US
Telephone Number	:	361-575-8271
Fax Number	:	361-575-6520

Provider Business Practice Location Address
First Line	:	120 DAVID WADE DRIVE
Second Line	:
City	:	VICTORIA
State	:	TX
Zip	:	77905
Country	:	US
Telephone Number	:	361-575-8271
Fax Number	:	361-575-6520

Authorized Official
Title or Position	:	EXECUTIVE DIRECTOR
Name	:	MS. PAMELA E. HELM
Credential	:
Telephone Number	:	281-335-1000

Provider Enumeration Date	:	10/19/2006
Last Update Date	:	07/14/2009

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Directions to “DEVEREUX FOUNDATION ” Practice Location

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