Provider Demographics
NPI:1356565360
Name:TEXAS ADOLESCENT TREATMENT CENTER
Entity type:Organization
Organization Name:TEXAS ADOLESCENT TREATMENT CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:SERGIO
Authorized Official - Middle Name:
Authorized Official - Last Name:FERNANDEZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:210-568-8500
Mailing Address - Street 1:8550 HUEBNER RD
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78240-1803
Mailing Address - Country:US
Mailing Address - Phone:210-568-8550
Mailing Address - Fax:210-568-0624
Practice Address - Street 1:11845 WEST AVE
Practice Address - Street 2:APARTMENT 1015
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78216-2554
Practice Address - Country:US
Practice Address - Phone:210-772-9540
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-12
Last Update Date:2008-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX17401320800000X, 251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
No320800000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Mental Illness
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX147573301OtherCHIP
TX1475733Medicaid