Provider Demographics
NPI:1447672910
Name:SRP BEHAVIORAL HOSPITAL OF FORT WORTH LLC
Entity type:Organization
Organization Name:SRP BEHAVIORAL HOSPITAL OF FORT WORTH LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DELEGATED/AUTHORIZED OFFICIAL
Authorized Official - Prefix:
Authorized Official - First Name:BARBARA
Authorized Official - Middle Name:
Authorized Official - Last Name:SHOUSE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:502-680-2115
Mailing Address - Street 1:8343 DOUGLAS AVE STE 350
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75225-5887
Mailing Address - Country:US
Mailing Address - Phone:817-361-1991
Mailing Address - Fax:817-361-1993
Practice Address - Street 1:6200 OVERTON RIDGE BLVD
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76132-0000
Practice Address - Country:US
Practice Address - Phone:817-361-1991
Practice Address - Fax:817-361-1993
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-01-17
Last Update Date:2020-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX100246283Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes283Q00000XHospitalsPsychiatric Hospital
Provider Identifiers
StateIdentifier IDID TypeIssuer
454128Medicare Oscar/Certification