Provider Demographics
NPI:1114762382
Name:BEACON BEHAVIORAL OF TEXAS PA
Entity type:Organization
Organization Name:BEACON BEHAVIORAL OF TEXAS PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING SUPERVISOR
Authorized Official - Prefix:
Authorized Official - First Name:KIMBERLY
Authorized Official - Middle Name:
Authorized Official - Last Name:GLAVESKAS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:443-962-3945
Mailing Address - Street 1:550 WESTCOTT ST STE 520
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77007-9001
Mailing Address - Country:US
Mailing Address - Phone:713-864-6694
Mailing Address - Fax:713-864-6698
Practice Address - Street 1:550 WESTCOTT ST STE 520
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77007-9001
Practice Address - Country:US
Practice Address - Phone:713-864-6694
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:BEACON BEHAVIORAL OF TEXAS PA
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2024-06-28
Last Update Date:2024-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Multi-Specialty