MEDICARE: NOAH'S GLEN RESIDENTIAL TREATMENT CENTER

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	3245S0500X	Children's Substance Abuse Rehabilitation Facility	2362A	TX

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	2362A	OTHER	TX	DSHS

General Provider Information

NPI Number	:	1679638639
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	NOAH'S GLEN RESIDENTIAL TREATMENT CENTER

Provider Business Mailing Address
First Line	:	2121 MANSFIELD ST
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77091-4033
Country	:	US
Telephone Number	:	713-683-9144
Fax Number	:	713-683-9143

Provider Business Practice Location Address
First Line	:	2121 MANSFIELD ST
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77091-4033
Country	:	US
Telephone Number	:	713-683-9144
Fax Number	:	713-683-9143

Authorized Official
Title or Position	:	CEO
Name	:	DUDLEY T FARENTHOLD
Credential	:	LCSW
Telephone Number	:	713-683-9144

Provider Enumeration Date	:	12/27/2006
Last Update Date	:	08/22/2020

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Directions to “NOAH'S GLEN RESIDENTIAL TREATMENT CENTER ” Practice Location

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