1972654820 NPI number — HIGHLAND LAKES BEHAVIORAL MEDICINE, PLLC

Table of content: (NPI 1972654820)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1972654820 NPI number — HIGHLAND LAKES BEHAVIORAL MEDICINE, PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
HIGHLAND LAKES BEHAVIORAL MEDICINE, PLLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
COVE COUNSELING CENTER
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1972654820
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1001 AVENUE E
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MARBLE FALLS
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
78654-5227
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
830-265-4554
Provider Business Mailing Address Fax Number:
866-602-0977

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1007 WEST HIGHWAY 190
Provider Second Line Business Practice Location Address:
SUITE B
Provider Business Practice Location Address City Name:
COPPERAS COVE
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
76522
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
254-542-7200
Provider Business Practice Location Address Fax Number:
866-602-0977
Provider Enumeration Date:
01/16/2007

Additional Information

Authorized Official

Authorized Official Last Name:
HUPP
Authorized Official First Name:
GREG
Authorized Official Middle Name:
Authorized Official Title or Position:
DIRECTOR
Authorized Official Telephone Number:
830-265-4554

Provider Taxonomy Codes

  • Taxonomy code: 101YP2500X , with the licence number:  11624 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "X" .
  • Taxonomy code: 103G00000X , with the licence number: 31593 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "X" .

Other Provider's Identifiers (legacy, non-NPI)





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