MEDICARE: AGAPE MIND SERVICES

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	261QM0850X	Adult Mental Health Clinic/Center	J1950	TX

General Provider Information

NPI Number	:	1679704787
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	AGAPE MIND SERVICES

Provider Business Mailing Address
First Line	:	2820 VILLAGE PKWY STE 620
Second Line	:
City	:	HIGHLAND VILLAGE
State	:	TX
Zip	:	75077-3298
Country	:	US
Telephone Number	:	972-317-7800
Fax Number	:	972-317-3032

Provider Business Practice Location Address
First Line	:	2820 VILLAGE PKWY STE 620
Second Line	:
City	:	HIGHLAND VILLAGE
State	:	TX
Zip	:	75077-3298
Country	:	US
Telephone Number	:	972-317-7800
Fax Number	:	972-317-3032

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. LOUIS EDWARD COSTELLO
Credential	:	MD
Telephone Number	:	972-317-7800

Provider Enumeration Date	:	08/06/2009
Last Update Date	:	06/19/2015

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