Provider Demographics
NPI:1023150877
Name:BLUEBONNET TRAILS COMMUNITY MHMR CENTER
Entity type:Organization
Organization Name:BLUEBONNET TRAILS COMMUNITY MHMR CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING COORDINATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:NORALISA
Authorized Official - Middle Name:
Authorized Official - Last Name:WILLIAMS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:512-244-8374
Mailing Address - Street 1:1009 N GEORGETOWN ST
Mailing Address - Street 2:
Mailing Address - City:ROUND ROCK
Mailing Address - State:TX
Mailing Address - Zip Code:78664-3289
Mailing Address - Country:US
Mailing Address - Phone:512-255-1720
Mailing Address - Fax:512-244-8371
Practice Address - Street 1:1009 N GEORGETOWN ST
Practice Address - Street 2:
Practice Address - City:ROUND ROCK
Practice Address - State:TX
Practice Address - Zip Code:78664-3289
Practice Address - Country:US
Practice Address - Phone:512-255-1720
Practice Address - Fax:512-244-8371
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-12
Last Update Date:2023-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXNO LICENSE163WP0808X, 164X00000X, 171R00000X, 2084P0800X, 363LA2200X, 363LP0808X, 171M00000X
TXNO LICESE163WP0809X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171M00000XOther Service ProvidersCase Manager/Care CoordinatorGroup - Multi-Specialty
No163WP0808XNursing Service ProvidersRegistered NursePsychiatric/Mental HealthGroup - Multi-Specialty
No163WP0809XNursing Service ProvidersRegistered NursePsychiatric/Mental Health, AdultGroup - Multi-Specialty
No164X00000XNursing Service ProvidersLicensed Vocational NurseGroup - Multi-Specialty
No171R00000XOther Service ProvidersInterpreterGroup - Multi-Specialty
No2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Multi-Specialty
No363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult HealthGroup - Multi-Specialty
No363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1268443 05Medicaid
TX1268443 02Medicaid
TX0197201 01Medicaid
TX1268443 04Medicaid