Provider Demographics
NPI:1316370562
Name:CENTRAL TEXAS GERIATRIC BEHAVIORAL HEALTH
Entity type:Organization
Organization Name:CENTRAL TEXAS GERIATRIC BEHAVIORAL HEALTH
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:JOSEPH
Authorized Official - Middle Name:SLADE
Authorized Official - Last Name:BOSARGE
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:512-680-3013
Mailing Address - Street 1:2504 RAE DELL AVE
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78704-4735
Mailing Address - Country:US
Mailing Address - Phone:512-284-3712
Mailing Address - Fax:855-700-9866
Practice Address - Street 1:2504 RAE DELL AVE
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78704-4735
Practice Address - Country:US
Practice Address - Phone:512-284-3712
Practice Address - Fax:855-700-9866
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-08-12
Last Update Date:2013-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX34161103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Multi-Specialty