Provider Demographics
NPI:1538192711
Name:HEALTH STREET HEALTHCARE, INC.
Entity type:Organization
Organization Name:HEALTH STREET HEALTHCARE, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:NICHOLAS
Authorized Official - Middle Name:O
Authorized Official - Last Name:EZENWA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:713-773-4200
Mailing Address - Street 1:8449 W. BELFORT STREET
Mailing Address - Street 2:#222
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77071
Mailing Address - Country:US
Mailing Address - Phone:713-773-4200
Mailing Address - Fax:713-773-4201
Practice Address - Street 1:8449 W. BELFORT STREET
Practice Address - Street 2:#222
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77071
Practice Address - Country:US
Practice Address - Phone:713-773-4200
Practice Address - Fax:713-773-4201
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-09
Last Update Date:2007-12-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX000000103TB0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TB0200XBehavioral Health & Social Service ProvidersPsychologistCognitive & BehavioralGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX00W918Medicare PIN