DATE PREPARED: 03-21-20 H H S C REPORT NO.: HC062096 TIME PREPARED: 06:54 HCS PROGRAM PROVIDER INFORMATION PAGE : 25 WAIVER CONTRACT AREA: 6 MRA: 030 AUSTIN TRAVIS INTEGRAL CARE ------------------------------------------------------------------------------ PROVIDER: 76R A BETTER HCS HOME INC CONTRACT NUMBER : 001009724 A BETTER HCS HOME INC APPLICANT CONTACT: DARCY BENFORD PHONE: (254) 498-9361 FAX: (254) 662-9121 PHYSICAL ADDRESS : 625 BRUSY CREEK, HEWITT, TX 76643 CONSUMERS ENROLLED IN THE FOLLOWING COUNTIES: BELL 1 BOSQUE 1 FALLS 2 HILL 1 MCLENNAN 13 TRAVIS 1 CONSUMERS ENROLLED STATEWIDE 36 ------------------------------------------------------------------------------ PROVIDER: 79E A FAIR CHOICE, INC. CONTRACT NUMBER : 001021409 A FAIR CHOICE, INC. APPLICANT CONTACT: LEDESMA KRISTY NICOLE PHONE: (817) 320-6836 FAX: (817) 200-7572 PHYSICAL ADDRESS : 3017 MEDLIN DR SUITE 200, ARLINGTON, TX 76015 CONSUMERS ENROLLED IN THE FOLLOWING COUNTIES: NONE CONSUMERS ENROLLED STATEWIDE 39 ------------------------------------------------------------------------------ PROVIDER: 7E2 A FAMILY CHOICE CDS LLC CONTRACT NUMBER : 001030799 A FAMILY CHOICE CDS LLC APPLICANT CONTACT: CYNTHIA SMITH PHONE: (678) 674-9996 FAX: (214) 723-7016 PHYSICAL ADDRESS : 7104 MIDDLEBURG DRIVE, PLANO, TX 75074 CONSUMERS ENROLLED IN THE FOLLOWING COUNTIES: NONE CONSUMERS ENROLLED STATEWIDE 1 ------------------------------------------------------------------------------ PROVIDER: 8XA A FAMILY OF NEW BEGINNINGS INC CONTRACT NUMBER : 001009211 A FAMILY OF NEW BEGINNING INC APPLICANT CONTACT: LATONIA DAVIDSON PHONE: (512) 809-9576 FAX: (512) 973-9171 PHYSICAL ADDRESS : 612 JUSTEFORD DRIVE, PFLUGERVILLE, TX 78660 CONSUMERS ENROLLED IN THE FOLLOWING COUNTIES: BASTROP 4 GONZALES 4 TRAVIS 25 WILLIAMSON 3 CONSUMERS ENROLLED STATEWIDE 40 ------------------------------------------------------------------------------ PROVIDER: 7E4 A PRECIOUS PLACE FOR ME LLC CONTRACT NUMBER : 001022149 A PRECIOUS PLACE FOR ME LLC APPLICANT CONTACT: MICHAEL WILSON PHONE: (254) 213-1917 FAX: (254) 833-5153 PHYSICAL ADDRESS : 3501 VIEWCREST DR, KILLEEN, TX 76549 CONSUMERS ENROLLED IN THE FOLLOWING COUNTIES: BELL 10 MCLENNAN 1 CONSUMERS ENROLLED STATEWIDE 11 ------------------------------------------------------------------------------ PROVIDER: 8XC A TAP INC CONTRACT NUMBER : 001009216 A TAP INC APPLICANT CONTACT: TONY ALEXANDER PHONE: (281) 433-6529 FAX: (832) 360-2768 PHYSICAL ADDRESS : 9118 MESA DRIVE, HOUSTON, TX 77028 CONSUMERS ENROLLED IN THE FOLLOWING COUNTIES: NONE CONSUMERS ENROLLED STATEWIDE 39 ------------------------------------------------------------------------------ PROVIDER: 7EI A 1 AFFINITY CARE LLC CONTRACT NUMBER : 001029059 A 1 AFFINITY CARE LLC DATE PREPARED: 03-21-20 H H S C REPORT NO.: HC062096 TIME PREPARED: 06:54 HCS PROGRAM PROVIDER INFORMATION PAGE : 26 WAIVER CONTRACT AREA: 6 MRA: 030 AUSTIN TRAVIS INTEGRAL CARE APPLICANT CONTACT: SYLVANUS NACHERI PHONE: (281) 241-4344 FAX: (000) 000-0000 PHYSICAL ADDRESS : 11811 NORTH FREEWAY SUITE 500, HOUSTON, TX 77060 CONSUMERS ENROLLED IN THE FOLLOWING COUNTIES: NONE CONSUMERS ENROLLED STATEWIDE 0 ------------------------------------------------------------------------------ PROVIDER: 79Y ABBA UNLIMITED LLC CONTRACT NUMBER : 001021536 ABBA UNLIMITED LLC APPLICANT CONTACT: EDWARDS JENNIFER PHONE: (512) 294-5779 FAX: (800) 359-9460 PHYSICAL ADDRESS : 1720 LOMITA DR, LEANDER, TX 78641 CONSUMERS ENROLLED IN THE FOLLOWING COUNTIES: BURNET 1 GUADALUPE 1 TRAVIS 9 WILLIAMSON 13 CONSUMERS ENROLLED STATEWIDE 24 ------------------------------------------------------------------------------ PROVIDER: 8TQ ABEL KARE CONCEPTS INC CONTRACT NUMBER : 001008778 ABEL KARE CONCEPTS INC APPLICANT CONTACT: ABEL CORTEZ PHONE: (512) 784-0886 FAX: (512) 835-2675 PHYSICAL ADDRESS : 3700 W PARMER LN STE 110, AUSTIN, TX 78727 CONSUMERS ENROLLED IN THE FOLLOWING COUNTIES: CALDWELL 1 TRAVIS 12 WILLIAMSON 1 CONSUMERS ENROLLED STATEWIDE 31 ------------------------------------------------------------------------------ PROVIDER: 8QT ABIDING CHOICE, INC. CONTRACT NUMBER : 001008404 ABIDING CHOICE, INC. APPLICANT CONTACT: TIFFANY GERREN PHONE: (512) 446-4846 FAX: (512) 446-4742 PHYSICAL ADDRESS : 204 CO RD 308, ROCKDALE, TX 76567 CONSUMERS ENROLLED IN THE FOLLOWING COUNTIES: BASTROP 5 BELL 95 BRAZOS 1 BURLESON 1 CALDWELL 1 CORYELL 4 FALLS 1 FAYETTE 2 LAMPASAS 4 LEE 19 MCLENNAN 2 MILAM 20 TRAVIS 20 WILLIAMSON 18 CONSUMERS ENROLLED STATEWIDE 247 ------------------------------------------------------------------------------ PROVIDER: 8SH ABILITIES INC CONTRACT NUMBER : 001008642 ABILITIES INC APPLICANT CONTACT: ARNULFO GONZALEZ PHONE: (972) 709-7666 FAX: (972) 709-7237 PHYSICAL ADDRESS : PASTOR BAILEY DR. STE. 101A, DALLAS, TX 75237 CONSUMERS ENROLLED IN THE FOLLOWING COUNTIES: HILL 1 MCLENNAN 1 TRAVIS 1 CONSUMERS ENROLLED STATEWIDE 99 ------------------------------------------------------------------------------ PROVIDER: 7F1 ABOUT LIVING HEALTHCARE SERVIC CONTRACT NUMBER : 001029608 ABOUT LIVING HEALTHCARE SERVICES LLC APPLICANT CONTACT: IHENETU LEONARD PHONE: (832) 692-3851 FAX: (713) 677-0498 PHYSICAL ADDRESS : 7600 CREEKBEND DR APT 823, HOUSTON, TX 77071-1849 CONSUMERS ENROLLED IN THE FOLLOWING COUNTIES: NONE CONSUMERS ENROLLED STATEWIDE 0 ------------------------------------------------------------------------------ PROVIDER: 77B ADONAI INC CONTRACT NUMBER : 001021965 ADONAI INC APPLICANT CONTACT: RYAN KIPPES PHONE: (214) 289-4933 FAX: (940) 312-7805 PHYSICAL ADDRESS : 2080 N STATE HWY 360 STE 230, GRAND PRAIRIE, TX 75050 DATE PREPARED: 03-21-20 H H S C REPORT NO.: HC062096 TIME PREPARED: 06:54 HCS PROGRAM PROVIDER INFORMATION PAGE : 27 WAIVER CONTRACT AREA: 6 MRA: 030 AUSTIN TRAVIS INTEGRAL CARE CONSUMERS ENROLLED IN THE FOLLOWING COUNTIES: NONE CONSUMERS ENROLLED STATEWIDE 11 ------------------------------------------------------------------------------ PROVIDER: 7H2 ADVANCED LIVING OPTIONS INC CONTRACT NUMBER : 001030879 ADVANCED LIVING OPTIONS INC APPLICANT CONTACT: TAMMY MARTIN PHONE: (210) 551-9284 FAX: (210) 590-9503 PHYSICAL ADDRESS : 12126 WILDROSE HILL, SAN ANTONIO, TX 78230 CONSUMERS ENROLLED IN THE FOLLOWING COUNTIES: NONE CONSUMERS ENROLLED STATEWIDE 0 ------------------------------------------------------------------------------ PROVIDER: 7DZ ADVOCATES UNITED AND COMPANY CONTRACT NUMBER : 001022127 ADVOCATES UNITED AND COMPANY APPLICANT CONTACT: SANDERS KATRINA PHONE: (832) 776-4594 FAX: (888) 604-2822 PHYSICAL ADDRESS : 11655 BRIAR FOREST UNIT 78, HOUSTON, TX 77077 CONSUMERS ENROLLED IN THE FOLLOWING COUNTIES: NONE CONSUMERS ENROLLED STATEWIDE 5 ------------------------------------------------------------------------------ PROVIDER: 7FJ AGRICH HEALTH SERVICE LLC CONTRACT NUMBER : 001029785 AGRICH HEALTH SERVICE LLC APPLICANT CONTACT: FRANCES ANYIGBO PHONE: (832) 444-3714 FAX: (832) 945-3977 PHYSICAL ADDRESS : 7738 DEEP GREEN DRIVE, ROSENBERG, TX 77469-4672 CONSUMERS ENROLLED IN THE FOLLOWING COUNTIES: NONE CONSUMERS ENROLLED STATEWIDE 1 ------------------------------------------------------------------------------ PROVIDER: 8YM AHORA Y SIEMPRE INC CONTRACT NUMBER : 001009388 AHORA Y SIEMPRE INC APPLICANT CONTACT: FRANCISCO GONZALEZ PHONE: (214) 741-6359 FAX: (214) 741-6389 PHYSICAL ADDRESS : 1412 MAIN STREET STE 2500, DALLAS, TX 75202 CONSUMERS ENROLLED IN THE FOLLOWING COUNTIES: GONZALES 1 GUADALUPE 2 TRAVIS 13 WILLIAMSON 4 CONSUMERS ENROLLED STATEWIDE 338 ------------------------------------------------------------------------------ PROVIDER: 894 ALLIANCE COMMUNITY CARE, LLC CONTRACT NUMBER : 001008125 ALLIANCE COMMUNITY CARE, LLC APPLICANT CONTACT: IN K. HWANG PHONE: (512) 215-4600 FAX: (512) 215-4366 PHYSICAL ADDRESS : ORSOBELLO COVE, CEDAR PARK, TX 78613 CONSUMERS ENROLLED IN THE FOLLOWING COUNTIES: LAMPASAS 1 CONSUMERS ENROLLED STATEWIDE 1 ------------------------------------------------------------------------------ PROVIDER: 797 AMAZING LIVING HCS LLC CONTRACT NUMBER : 001021795 AMAZING LIVING HCS LLC APPLICANT CONTACT: CARMALITA CARMOUCHE PHONE: (903) 917-3202 FAX: (888) 474-6401 PHYSICAL ADDRESS : 11101 FM 1960 SUITE C, HUFFMAN, TX 77336 CONSUMERS ENROLLED IN THE FOLLOWING COUNTIES: NONE CONSUMERS ENROLLED STATEWIDE 13 ------------------------------------------------------------------------------ DATE PREPARED: 03-21-20 H H S C REPORT NO.: HC062096 TIME PREPARED: 06:54 HCS PROGRAM PROVIDER INFORMATION PAGE : 28 WAIVER CONTRACT AREA: 6 MRA: 030 AUSTIN TRAVIS INTEGRAL CARE PROVIDER: 7BA ANDREW M CONTRERAS III CONTRACT NUMBER : 001021649 MIRCLES HAPPEN APPLICANT CONTACT: CONTRERAS I ANDREW PHONE: (210) 491-4419 FAX: (210) 491-5244 PHYSICAL ADDRESS : 2881 THOUSAND OAKS, SAN ANTONIO, TX 78232 CONSUMERS ENROLLED IN THE FOLLOWING COUNTIES: NONE CONSUMERS ENROLLED STATEWIDE 0 ------------------------------------------------------------------------------ PROVIDER: 8NH ANGEL COMMUNITY SERVICES, LLC CONTRACT NUMBER : 001029053 ANGEL COMMUNITY SERVICES LLC APPLICANT CONTACT: SHERRYE NAIL PHONE: (940) 456-4288 FAX: (940) 549-5263 PHYSICAL ADDRESS : 2929 HSW. 16 SOUTH, GRAHAM, TX 76450 CONSUMERS ENROLLED IN THE FOLLOWING COUNTIES: NONE CONSUMERS ENROLLED STATEWIDE 0 ------------------------------------------------------------------------------ PROVIDER: 7C6 ANGELES DE LA TIERRA LLC CONTRACT NUMBER : 001021788 ANGELES DE LA TIERRA, LLC APPLICANT CONTACT: AIDEYAN JOSHUA PHONE: (318) 548-8458 FAX: (832) 447-1335 PHYSICAL ADDRESS : 12114 FAIRPOINT DRIVE, HOUSTON, TX 77099 CONSUMERS ENROLLED IN THE FOLLOWING COUNTIES: HILL 1 CONSUMERS ENROLLED STATEWIDE 44 ------------------------------------------------------------------------------ PROVIDER: 77A ANITA DAVIS WILCOX CONTRACT NUMBER : 001009919 LIVING WITH PURPOSE APPLICANT CONTACT: ANITA WILCOX PHONE: (817) 253-0742 FAX: PHYSICAL ADDRESS : 11200 PLEASANTWOOD LN, FORT WORTH, TX 76140 CONSUMERS ENROLLED IN THE FOLLOWING COUNTIES: NONE CONSUMERS ENROLLED STATEWIDE 32 ------------------------------------------------------------------------------ PROVIDER: 8NK ANOINTED CARING HOMES, INC. CONTRACT NUMBER : 001030591 ANOINTED CARING HOMES INC APPLICANT CONTACT: NICOLE WILSON PHONE: (281) 861-6500 FAX: (281) 861-6506 PHYSICAL ADDRESS : 5444 N FRY RD, SUITE E, KATY, TX 77449 CONSUMERS ENROLLED IN THE FOLLOWING COUNTIES: NONE CONSUMERS ENROLLED STATEWIDE 100 ------------------------------------------------------------------------------ PROVIDER: 8WQ APPLIED LIVING SOLUTIONS LLC CONTRACT NUMBER : 001009170 APPLIED LIVING SOLUTIONS LLC APPLICANT CONTACT: CYNDY BURLESON PHONE: (512) 632-1526 FAX: (512) 442-1372 PHYSICAL ADDRESS : 221 CR 4748, KEMPNER, TX 76539 CONSUMERS ENROLLED IN THE FOLLOWING COUNTIES: BELL 7 CORYELL 2 LAMPASAS 1 TRAVIS 7 CONSUMERS ENROLLED STATEWIDE 20 ------------------------------------------------------------------------------ PROVIDER: 87W APPROVED QUALITY CARE TEXAS,INC. CONTRACT NUMBER : 001007872 APPROVED QUALITY CARE TEXAS,INC. APPLICANT CONTACT: GERALD A. CHAVEZ PHONE: (512) 627-7880 FAX: (512) 280-4787 PHYSICAL ADDRESS : 1004 MEREDITH DRIVE, AUSTIN, TX 78748 DATE PREPARED: 03-21-20 H H S C REPORT NO.: HC062096 TIME PREPARED: 06:54 HCS PROGRAM PROVIDER INFORMATION PAGE : 29 WAIVER CONTRACT AREA: 6 MRA: 030 AUSTIN TRAVIS INTEGRAL CARE CONSUMERS ENROLLED IN THE FOLLOWING COUNTIES: BASTROP 18 BELL 1 BURLESON 3 CALDWELL 2 GUADALUPE 2 LEE 4 TRAVIS 11 WILLIAMSON 2 CONSUMERS ENROLLED STATEWIDE 105 ------------------------------------------------------------------------------ PROVIDER: 7BW ASSURANCE PERSONAL CARE & COMM CONTRACT NUMBER : 001021752 ASSURANCE PERSONAL CARE & COMMUNITY APPLICANT CONTACT: NWOKORIE JOHNSON PHONE: (281) 701-1084 FAX: (713) 977-7728 PHYSICAL ADDRESS : 19703 MOSS BARK TRAIL, RICHMOND, TX 77407 CONSUMERS ENROLLED IN THE FOLLOWING COUNTIES: NONE CONSUMERS ENROLLED STATEWIDE 0 ------------------------------------------------------------------------------ PROVIDER: 8ZG ASSURED QUALITY CARE SERVICES CONTRACT NUMBER : 001009480 ASSURED QUALITY CARE HCS SERVICES APPLICANT CONTACT: STACY WILLIAMS ROSS PHONE: (936) 414-0988 FAX: (281) 272-1467 PHYSICAL ADDRESS : 7544 FM 1960 EAST #352, HUMBLE, TX 77346 CONSUMERS ENROLLED IN THE FOLLOWING COUNTIES: LEON 2 MCLENNAN 1 CONSUMERS ENROLLED STATEWIDE 67 ------------------------------------------------------------------------------ PROVIDER: 816 AUTISTIC TREATMENT CENTER INC CONTRACT NUMBER : 001009932 AUTISTIC TREATMENT CENTER INC APPLICANT CONTACT: ANNA HUNDLEY PHONE: (972) 644-2076 FAX: (972) 644-5650 PHYSICAL ADDRESS : 10503 METRIC DR, DALLAS, TX 75243 CONSUMERS ENROLLED IN THE FOLLOWING COUNTIES: NONE CONSUMERS ENROLLED STATEWIDE 31 ------------------------------------------------------------------------------ PROVIDER: 7E9 AYONG HEALTHCARE LLC CONTRACT NUMBER : 001030307 AYONG HEALTHCARE LLC APPLICANT CONTACT: SIMO LINDA PHONE: (832) 417-3042 FAX: PHYSICAL ADDRESS : 13531 LA CONCHA LN., HOUSTON, TX 77083 CONSUMERS ENROLLED IN THE FOLLOWING COUNTIES: WILLIAMSON 2 CONSUMERS ENROLLED STATEWIDE 26 ------------------------------------------------------------------------------ PROVIDER: 8SU BECK AND JOHNSON COMMUNITY SERVICES CONTRACT NUMBER : 001022090 BECK AND JOHNSON COMMUNITY SERVICES APPLICANT CONTACT: JOHNSON CASSANDRA PHONE: (713) 884-5629 FAX: (281) 310-8284 PHYSICAL ADDRESS : 6401 BINGLE STE 106, HOUSTON, TX 77092 CONSUMERS ENROLLED IN THE FOLLOWING COUNTIES: NONE CONSUMERS ENROLLED STATEWIDE 3 ------------------------------------------------------------------------------ PROVIDER: 8EF BELLTECH ENTERPRISES, INC. CONTRACT NUMBER : 001009036 BELLTECH ENTERPRISES,INC. APPLICANT CONTACT: RAFFY BELL PHONE: (281) 679-0541 FAX: (281) 679-0524 PHYSICAL ADDRESS : 12000 RICHMOND AVE, STE 130, HOUSTON, TX 77082 CONSUMERS ENROLLED IN THE FOLLOWING COUNTIES: NONE CONSUMERS ENROLLED STATEWIDE 23 ------------------------------------------------------------------------------ DATE PREPARED: 03-21-20 H H S C REPORT NO.: HC062096 TIME PREPARED: 06:54 HCS PROGRAM PROVIDER INFORMATION PAGE : 30 WAIVER CONTRACT AREA: 6 MRA: 030 AUSTIN TRAVIS INTEGRAL CARE PROVIDER: 88G BERRY FAMILY SERVICES, INC. CONTRACT NUMBER : 001021471 BERRY FAMILY SERVICES, INC. APPLICANT CONTACT: BERRY CINDY PHONE: (972) 412-4707 FAX: (972) 202-0314 PHYSICAL ADDRESS : 5700 ROWLETT DR #110, ROWLETT, TX 75089 CONSUMERS ENROLLED IN THE FOLLOWING COUNTIES: BELL 3 BURNET 1 CONSUMERS ENROLLED STATEWIDE 1044 ------------------------------------------------------------------------------ PROVIDER: 7FV BEST COMFORT HEALTH SERVICES L CONTRACT NUMBER : 001029730 BEST COMFORT HEALTH SERVICES LLC APPLICANT CONTACT: OBUKWELU EJIKEME PHONE: (713) 992-3341 FAX: (281) 498-1163 PHYSICAL ADDRESS : 13707 SUNMOUNT PINES DR, HOUSTON, TX 77083 CONSUMERS ENROLLED IN THE FOLLOWING COUNTIES: NONE CONSUMERS ENROLLED STATEWIDE 0 ------------------------------------------------------------------------------ PROVIDER: 8CY BETHESDA LUTHERAN HOMES AND SERVICES, INC. CONTRACT NUMBER : 001009701 BETHESDA LUTHERAN HOMES AND SERVICE APPLICANT CONTACT: TAMICO MELVIN PHONE: (281) 516-4024 FAX: (281) 351-5897 PHYSICAL ADDRESS : 729, CYPRESS, TX 77410-0729 CONSUMERS ENROLLED IN THE FOLLOWING COUNTIES: NONE CONSUMERS ENROLLED STATEWIDE 56 ------------------------------------------------------------------------------ PROVIDER: 8T4 BRANDON TRIMONE MODKINS CONTRACT NUMBER : 001008611 BRANDON TRIMONE MODKINS APPLICANT CONTACT: JULIA KANTER PHONE: (512) 369-3586 FAX: (512) 904-0880 PHYSICAL ADDRESS : 8606 DANDELION TRL, AUSTIN, TX 78745 CONSUMERS ENROLLED IN THE FOLLOWING COUNTIES: NONE CONSUMERS ENROLLED STATEWIDE 0 ------------------------------------------------------------------------------ PROVIDER: 76Y BRENDA L DICKENS CONTRACT NUMBER : 001009739 BRENDA L DICKENS APPLICANT CONTACT: BRENDA DICKENS PHONE: (281) 438-8166 FAX: PHYSICAL ADDRESS : 6619 INDIAN FALLS DR, MISSOURI CITY, TX 77489 CONSUMERS ENROLLED IN THE FOLLOWING COUNTIES: NONE CONSUMERS ENROLLED STATEWIDE 0 ------------------------------------------------------------------------------ PROVIDER: 7GP BRIGHT FUTURE HCS LLC CONTRACT NUMBER : 001030596 BRIGHT FUTURE HCS LLC APPLICANT CONTACT: FLORA UCHEA PHONE: (832) 531-5935 FAX: (000) 000-0000 PHYSICAL ADDRESS : 11110 JESSDALE CT, RICHMOND, TX 77407 CONSUMERS ENROLLED IN THE FOLLOWING COUNTIES: NONE CONSUMERS ENROLLED STATEWIDE 0 ------------------------------------------------------------------------------ PROVIDER: 7FE C AND J HEALTHCARE SERVICES LL CONTRACT NUMBER : 001029624 C AND J HEALTHCARE SERVICES LLC APPLICANT CONTACT: ANOWEY JUSTIN PHONE: (281) 972-9609 FAX: (346) 816-7183 PHYSICAL ADDRESS : 3018 HURST GREEN LN, FRESNO, TX 77545 CONSUMERS ENROLLED IN THE FOLLOWING COUNTIES: NONE DATE PREPARED: 03-21-20 H H S C REPORT NO.: HC062096 TIME PREPARED: 06:54 HCS PROGRAM PROVIDER INFORMATION PAGE : 31 WAIVER CONTRACT AREA: 6 MRA: 030 AUSTIN TRAVIS INTEGRAL CARE CONSUMERS ENROLLED STATEWIDE 0 ------------------------------------------------------------------------------ PROVIDER: 7FW CARE DIVINE OF GUARDIAN ANGEL CONTRACT NUMBER : 001029838 CARE DIVINE OF GUARDIAN ANGEL LLC APPLICANT CONTACT: IKE MARGARET PHONE: (915) 204-6727 FAX: (915) 849-7825 PHYSICAL ADDRESS : 3135 TRAWOOD DR, EL PASO, TX 79936 CONSUMERS ENROLLED IN THE FOLLOWING COUNTIES: NONE CONSUMERS ENROLLED STATEWIDE 54 ------------------------------------------------------------------------------ PROVIDER: 7AI CAROLYN'S UNIQUE LEARNING ACTIVITY CONTRACT NUMBER : 001029837 CAROLYN'S UNIQUE LEARNING ACTIVITY CENTE APPLICANT CONTACT: CAROLYN JOHNSON PHONE: (214) 664-6900 FAX: (866) 302-8828 PHYSICAL ADDRESS : 1460 EASTGLEN BLVD, MESQUITE, TX 75149 CONSUMERS ENROLLED IN THE FOLLOWING COUNTIES: NONE CONSUMERS ENROLLED STATEWIDE 27 ------------------------------------------------------------------------------ PROVIDER: 8VH CASA ESPERANZA INC CONTRACT NUMBER : 001008960 HOPE HOUSE APPLICANT CONTACT: DAWN HAMILTON PHONE: (512) 515-6889 FAX: (512) 515-6793 PHYSICAL ADDRESS : COUNTY ROAD 285, LIBERTY HILL, TX 78642 CONSUMERS ENROLLED IN THE FOLLOWING COUNTIES: WILLIAMSON 20 CONSUMERS ENROLLED STATEWIDE 20 ------------------------------------------------------------------------------ PROVIDER: 7DJ CHARLOTTE BOSTON SCOTT CONTRACT NUMBER : 001022055 JOYFUL DAYS APPLICANT CONTACT: CHARLOTTE SCOTT PHONE: (800) 420-5539 FAX: (318) 505-5160 PHYSICAL ADDRESS : 508 GLENWICK DR, DESOTO, TX 75115 CONSUMERS ENROLLED IN THE FOLLOWING COUNTIES: NONE CONSUMERS ENROLLED STATEWIDE 0 ------------------------------------------------------------------------------ PROVIDER: 8WP CHERYL KYLE CHRISTIAN CONTRACT NUMBER : 001029831 CHERYL KYLE CHRISTIAN APPLICANT CONTACT: KYLE CHRIST CHERYL PHONE: (281) 973-9273 FAX: (866) 447-8979 PHYSICAL ADDRESS : 4802 LAZY TIMBERS DR, HUMBLE, TX 77346 CONSUMERS ENROLLED IN THE FOLLOWING COUNTIES: NONE CONSUMERS ENROLLED STATEWIDE 43 ------------------------------------------------------------------------------ PROVIDER: 82A CHUCK C. OKEADU CONTRACT NUMBER : 001022153 SPECIAL HOME CARE LIVING CENTER APPLICANT CONTACT: SAMUEL A. OKEADU PHONE: (713) 771-3133 FAX: (713) 771-3113 PHYSICAL ADDRESS : 9898 BISSONNET STE 585, HOUSTON, TX 77036 CONSUMERS ENROLLED IN THE FOLLOWING COUNTIES: NONE CONSUMERS ENROLLED STATEWIDE 25 ------------------------------------------------------------------------------ PROVIDER: 7DK CITI HEALTH GROUP INC CONTRACT NUMBER : 001022061 CITI HEALTH GROUP INC DATE PREPARED: 03-21-20 H H S C REPORT NO.: HC062096 TIME PREPARED: 06:54 HCS PROGRAM PROVIDER INFORMATION PAGE : 32 WAIVER CONTRACT AREA: 6 MRA: 030 AUSTIN TRAVIS INTEGRAL CARE APPLICANT CONTACT: DANIEL O. ORJI PHONE: (346) 932-7423 FAX: (832) 925-8562 PHYSICAL ADDRESS : 8303 SOUTH WEST FREEWAY STE. 100, HOUSTON, TX 77074 CONSUMERS ENROLLED IN THE FOLLOWING COUNTIES: NONE CONSUMERS ENROLLED STATEWIDE 9 ------------------------------------------------------------------------------ PROVIDER: 86D CLETUS O OKONKWO CONTRACT NUMBER : 001007402 ULTIMATE LIVING CENTER APPLICANT CONTACT: CLETUS O. OKONKWO PHONE: (281) 540-5358 FAX: (281) 540-5356 PHYSICAL ADDRESS : 19726 BELLAW WOODS DRIVE, HUMBLE, TX 77338-1932 CONSUMERS ENROLLED IN THE FOLLOWING COUNTIES: NONE CONSUMERS ENROLLED STATEWIDE 2 ------------------------------------------------------------------------------ PROVIDER: 89T COASTAL AREA SUPPORT ALTERNATIVES, INC. CONTRACT NUMBER : 001029434 COASTAL AREA SUPPORT ALTERNATIVES INC APPLICANT CONTACT: RAUL GONZALES PHONE: (361) 851-0688 FAX: (361) 851-0011 PHYSICAL ADDRESS : 5809 PATTON ST., CORPUS CHRISTI, TX 78414 CONSUMERS ENROLLED IN THE FOLLOWING COUNTIES: NONE CONSUMERS ENROLLED STATEWIDE 48 ------------------------------------------------------------------------------ PROVIDER: 837 COMMUNITY ACCESS INC CONTRACT NUMBER : 001007349 COMMUNITY ACCESS II APPLICANT CONTACT: TONYA MOSES PHONE: (903) 579-8527 FAX: (903) 526-0881 PHYSICAL ADDRESS : 2040 SHILOH ROAD, TYLER, TX 75703 CONSUMERS ENROLLED IN THE FOLLOWING COUNTIES: NONE CONSUMERS ENROLLED STATEWIDE 467 ------------------------------------------------------------------------------ PROVIDER: 8BT COMMUNITY CHOICE INCORPORATED CONTRACT NUMBER : 001007350 COMMUNITY CHOICE INCORPORATED APPLICANT CONTACT: TOM CONROY PHONE: (512) 835-8955 FAX: (512) 835-8812 PHYSICAL ADDRESS : 9609 NEW FOUNDLAND CIRCLE, AUSTIN, TX 78758 CONSUMERS ENROLLED IN THE FOLLOWING COUNTIES: BASTROP 1 GUADALUPE 1 TRAVIS 43 WILLIAMSON 14 CONSUMERS ENROLLED STATEWIDE 59 ------------------------------------------------------------------------------ PROVIDER: 830 COMMUNITY OPTIONS, INC. CONTRACT NUMBER : 001009680 COMMUNITY OPTIONS OF TEXAS APPLICANT CONTACT: GREG THOENNES PHONE: (512) 276-2088 FAX: (512) 284-8926 PHYSICAL ADDRESS : 12731 RESEARCH BLVD UNIT C300, AUSTIN, TX 78759 CONSUMERS ENROLLED IN THE FOLLOWING COUNTIES: BELL 1 BURNET 2 TRAVIS 45 WILLIAMSON 3 CONSUMERS ENROLLED STATEWIDE 468 ------------------------------------------------------------------------------ PROVIDER: 7D5 CORINTHIA LILLIE ALFORD CONTRACT NUMBER : 001022026 RUTHERFORD ENTERPRISE APPLICANT CONTACT: CORINTHIA L ALFORD PHONE: (972) 325-6527 FAX: (888) 251-5036 PHYSICAL ADDRESS : 4013 EASTON MEADOWS DR#101, GARLAND, TX 75043 CONSUMERS ENROLLED IN THE FOLLOWING COUNTIES: NONE DATE PREPARED: 03-21-20 H H S C REPORT NO.: HC062096 TIME PREPARED: 06:54 HCS PROGRAM PROVIDER INFORMATION PAGE : 33 WAIVER CONTRACT AREA: 6 MRA: 030 AUSTIN TRAVIS INTEGRAL CARE CONSUMERS ENROLLED STATEWIDE 0 ------------------------------------------------------------------------------ PROVIDER: 8GU COUNCIL OAKS COMMUNITY OPTIONS, LTD. CONTRACT NUMBER : 001008987 COUNCIL OAKS COMMUNITY OPTIONS, LTD APPLICANT CONTACT: CHRISTINA PORTILLO PHONE: (210) 646-0717 FAX: (210) 599-9789 PHYSICAL ADDRESS : 11901 TOEPPERWEIN RD STE 1001, SAN ANTONIO, TX 78233 CONSUMERS ENROLLED IN THE FOLLOWING COUNTIES: GUADALUPE 3 CONSUMERS ENROLLED STATEWIDE 30 ------------------------------------------------------------------------------ PROVIDER: 891 D & S RESIDENTIAL SERVICES, LP CONTRACT NUMBER : 001007352 D & S COMMUNITY SERVICES APPLICANT CONTACT: JOELLE BART PHONE: (512) 327-8484 FAX: (512) 327-7181 PHYSICAL ADDRESS : 225 S COMMONS FORD RD, AUSTIN, TX 78733 CONSUMERS ENROLLED IN THE FOLLOWING COUNTIES: BASTROP 24 BELL 6 BRAZOS 72 BURLESON 2 BURNET 11 CALDWELL 23 CORYELL 1 FAYETTE 2 FREESTONE 2 GONZALES 2 GRIMES 9 GUADALUPE 18 LEON 1 MCLENNAN 1 ROBERTSON 2 TRAVIS 224 WASHINGTON 120 WILLIAMSON 60 CONSUMERS ENROLLED STATEWIDE 2088 ------------------------------------------------------------------------------ PROVIDER: 7CP DAYBREAK COMMUNITY SERVICES TEXAS CONTRACT NUMBER : 001021876 DAYBREAK COMMUNITY SERVICES TEXAS L APPLICANT CONTACT: JOLYNN DUNN PHONE: (254) 774-8511 FAX: (254) 771-0848 PHYSICAL ADDRESS : 500 SPARTA ROAD, BELTON, TX 76513 CONSUMERS ENROLLED IN THE FOLLOWING COUNTIES: BELL 81 BOSQUE 3 BRAZOS 41 BURLESON 4 CALDWELL 1 CORYELL 3 FALLS 2 FAYETTE 1 FREESTONE 2 GRIMES 3 GUADALUPE 31 HAMILTON 2 HILL 1 LAMPASAS 7 LEE 2 LEON 1 LIMESTONE 17 MADISON 5 MCLENNAN 48 ROBERTSON 3 WILLIAMSON 1 CONSUMERS ENROLLED STATEWIDE 1605 ------------------------------------------------------------------------------ PROVIDER: 7G5 DDWD DEVELOPMENTAL HCS SERVICES INC CONTRACT NUMBER : 001030135 DDWD DEVELOPMENTAL HCS SERVICES INC APPLICANT CONTACT: DOW WENDY PHONE: (713) 476-0580 FAX: (800) 728-1294 PHYSICAL ADDRESS : 3511 PINEMONT DR #B5, HOUSTON, TX 77018 CONSUMERS ENROLLED IN THE FOLLOWING COUNTIES: NONE CONSUMERS ENROLLED STATEWIDE 15 ------------------------------------------------------------------------------ PROVIDER: 8XL DIVERSIFIED CARING HOMES PLLC CONTRACT NUMBER : 001009249 DIVERSIFIED CARING HOMES PLLC APPLICANT CONTACT: RENETTA HILLS PHONE: (832) 247-8705 FAX: (832) 582-3606 PHYSICAL ADDRESS : 16203 FLEETHAVEN LANE, HOUSTON, TX 77084 CONSUMERS ENROLLED IN THE FOLLOWING COUNTIES: NONE CONSUMERS ENROLLED STATEWIDE 9 ------------------------------------------------------------------------------ PROVIDER: 805 DOUBLETREE RESIDENTIAL SERVICES, INC. CONTRACT NUMBER : 001007356 DOUBLETREE RESIDENTIAL SERVICES, IN APPLICANT CONTACT: TERESA J. GREENHAW PHONE: (512) 291-8450 FAX: (512) 292-8744 PHYSICAL ADDRESS : 3225 W SLAUGHTER LANE, AUSTIN, TX 78748 DATE PREPARED: 03-21-20 H H S C REPORT NO.: HC062096 TIME PREPARED: 06:54 HCS PROGRAM PROVIDER INFORMATION PAGE : 34 WAIVER CONTRACT AREA: 6 MRA: 030 AUSTIN TRAVIS INTEGRAL CARE CONSUMERS ENROLLED IN THE FOLLOWING COUNTIES: TRAVIS 51 CONSUMERS ENROLLED STATEWIDE 51 ------------------------------------------------------------------------------ PROVIDER: 8DW DRACO SERVICES, INC. CONTRACT NUMBER : 001007357 DRACO SERVICES APPLICANT CONTACT: GORDON ISRAEL PHONE: (512) 426-3655 FAX: (512) 440-8800 PHYSICAL ADDRESS : 4025 MANCHACA RD, AUSTIN, TX 78704 CONSUMERS ENROLLED IN THE FOLLOWING COUNTIES: BASTROP 11 BURNET 1 CALDWELL 11 GONZALES 5 GUADALUPE 3 LEE 1 TRAVIS 61 WILLIAMSON 35 CONSUMERS ENROLLED STATEWIDE 229 ------------------------------------------------------------------------------ PROVIDER: 7GK EBONY BRADFORD CONTRACT NUMBER : 001030496 EBONY BRADFORD APPLICANT CONTACT: EBONY BRADFORD PHONE: (469) 939-7851 FAX: (682) 276-1368 PHYSICAL ADDRESS : 3204 SHARPVIEW LN, DALLAS, TX 75228 CONSUMERS ENROLLED IN THE FOLLOWING COUNTIES: NONE CONSUMERS ENROLLED STATEWIDE 0 ------------------------------------------------------------------------------ PROVIDER: 804 EDUCARE COMMUNITY LIVING CORPORATION - TEXAS CONTRACT NUMBER : 001007358 EDUCARE COMMUNITY LIVING CORPORATIO APPLICANT CONTACT: LORRIE ROBLEDO PHONE: (325) 642-0772 FAX: (512) 323-6732 PHYSICAL ADDRESS : 7700 CHEVY CHASE BLDG. 1 STE. 500, AUSTIN, TX 78752 CONSUMERS ENROLLED IN THE FOLLOWING COUNTIES: BASTROP 1 BURNET 1 CALDWELL 1 GUADALUPE 5 HILL 2 TRAVIS 100 WILLIAMSON 22 CONSUMERS ENROLLED STATEWIDE 1137 ------------------------------------------------------------------------------ PROVIDER: 831 EDUCARE COMMUNITY LIVING-NORMAL LIFE INC CONTRACT NUMBER : 001007359 EDUCARE COMMUNITY LIVING-NORMAL LIF APPLICANT CONTACT: ANNETTE L. JOHNSON PHONE: (512) 454-3795 FAX: (512) 302-3978 PHYSICAL ADDRESS : 8007 BURNET RD, AUSTIN, TX 78757 CONSUMERS ENROLLED IN THE FOLLOWING COUNTIES: BELL 53 BOSQUE 1 CORYELL 1 HILL 1 LIMESTONE 5 MCLENNAN 11 CONSUMERS ENROLLED STATEWIDE 239 ------------------------------------------------------------------------------ PROVIDER: 7FN ENCHANTMENT LIVING HHC LLC CONTRACT NUMBER : 001029579 ENCHANTMENT LIVING HHC LLC APPLICANT CONTACT: RANDLE CAROLYN PHONE: (210) 273-8016 FAX: (000) 000-0000 PHYSICAL ADDRESS : 5927 IRIS ISLE, SAN ANTONIO, TX 78218 CONSUMERS ENROLLED IN THE FOLLOWING COUNTIES: NONE CONSUMERS ENROLLED STATEWIDE 5 ------------------------------------------------------------------------------ PROVIDER: 85M EXCEPTIONAL EMPLOYMENT SERVICES, INC. CONTRACT NUMBER : 001007634 EXCEPTIONAL EMPLOYMENT SERVICES APPLICANT CONTACT: KIMBERLY STEVENSON PHONE: (512) 970-9313 FAX: (512) 926-5773 PHYSICAL ADDRESS : RIDGEPOINT DRIVE__#130, AUSTIN, TX 78754 CONSUMERS ENROLLED IN THE FOLLOWING COUNTIES: BASTROP 1 GONZALES 2 TRAVIS 66 WILLIAMSON 1 DATE PREPARED: 03-21-20 H H S C REPORT NO.: HC062096 TIME PREPARED: 06:54 HCS PROGRAM PROVIDER INFORMATION PAGE : 35 WAIVER CONTRACT AREA: 6 MRA: 030 AUSTIN TRAVIS INTEGRAL CARE CONSUMERS ENROLLED STATEWIDE 77 ------------------------------------------------------------------------------ PROVIDER: 86H FLORENCE BENNETT CONTRACT NUMBER : 001007691 DIVINITY CARE CENTER APPLICANT CONTACT: FLORENCE BENNETT PHONE: (713) 303-1325 FAX: (281) 407-7744 PHYSICAL ADDRESS : P. O. BOX 300079, HOUSTON, TX 77230 CONSUMERS ENROLLED IN THE FOLLOWING COUNTIES: MADISON 1 CONSUMERS ENROLLED STATEWIDE 9 ------------------------------------------------------------------------------ PROVIDER: 7EV FORCH SOLUTIONS, LLC CONTRACT NUMBER : 001029270 FORCH SOLUTIONS, LLC APPLICANT CONTACT: ANDREA FORCH PHONE: (713) 320-2754 FAX: (281) 990-6368 PHYSICAL ADDRESS : 9538 CHESTERFIELD LN, HOUSTON, TX 77051 CONSUMERS ENROLLED IN THE FOLLOWING COUNTIES: NONE CONSUMERS ENROLLED STATEWIDE 0 ------------------------------------------------------------------------------ PROVIDER: 8XD FOREVER FAMILIES INC CONTRACT NUMBER : 001009681 FOREVER FAMILIES INC APPLICANT CONTACT: SOPHIA FIELDS PHONE: (713) 661-2626 FAX: (713) 513-5958 PHYSICAL ADDRESS : 12125 HWY 6 STE A, FRESNO, TX 77545 CONSUMERS ENROLLED IN THE FOLLOWING COUNTIES: NONE CONSUMERS ENROLLED STATEWIDE 15 ------------------------------------------------------------------------------ PROVIDER: 7EE GENESIS DISABILITY CARE PROVID CONTRACT NUMBER : 001022177 GENESIS DISABILITY CARE PROVIDER IN APPLICANT CONTACT: BAKER SHARON PHONE: (512) 905-1327 FAX: (512) 337-5644 PHYSICAL ADDRESS : 1003 VINTAGE DR, LEANDER, TX 78641 CONSUMERS ENROLLED IN THE FOLLOWING COUNTIES: BELL 5 FALLS 8 LIMESTONE 2 MCLENNAN 17 TRAVIS 5 WILLIAMSON 4 CONSUMERS ENROLLED STATEWIDE 46 ------------------------------------------------------------------------------ PROVIDER: 8RN GOOD HOME COMMUNITY LIVING INC CONTRACT NUMBER : 001008491 GOOD HOME COMMUNITY LIVING INC APPLICANT CONTACT: GAIL CUNNINGHAM PHONE: (281) 905-0420 FAX: (866) 298-7350 PHYSICAL ADDRESS : 2254 COUNTY ROAD 179, ALVIN, TX 77511 CONSUMERS ENROLLED IN THE FOLLOWING COUNTIES: BELL 14 MCLENNAN 3 TRAVIS 17 WILLIAMSON 11 CONSUMERS ENROLLED STATEWIDE 168 ------------------------------------------------------------------------------ PROVIDER: 77P GREAT BEGINNINGS CAREER COUNSELING AND LIFE COACHING CONTRACT NUMBER : 001009843 GREAT BEGINNINGS CAREER COUNSELING APPLICANT CONTACT: LEWIS LATASHA PHONE: (832) 928-2818 FAX: (888) 355-4416 PHYSICAL ADDRESS : 17302 HOUSE & HAHL STE 329, CYPRESS, TX 77433 CONSUMERS ENROLLED IN THE FOLLOWING COUNTIES: NONE CONSUMERS ENROLLED STATEWIDE 30 ------------------------------------------------------------------------------ DATE PREPARED: 03-21-20 H H S C REPORT NO.: HC062096 TIME PREPARED: 06:54 HCS PROGRAM PROVIDER INFORMATION PAGE : 36 WAIVER CONTRACT AREA: 6 MRA: 030 AUSTIN TRAVIS INTEGRAL CARE PROVIDER: 7E3 GREAT LIFE SERVICES LLC CONTRACT NUMBER : 001022139 GREAT LIFE SERIVCES, LLC APPLICANT CONTACT: MARK XIMENEZ PHONE: (210) 656-1633 FAX: (210) 579-1314 PHYSICAL ADDRESS : 9033 AERO, STE. 101, SAN ANTONIO, TX 78217 CONSUMERS ENROLLED IN THE FOLLOWING COUNTIES: GONZALES 3 GUADALUPE 3 CONSUMERS ENROLLED STATEWIDE 32 ------------------------------------------------------------------------------ PROVIDER: 7DG GUARDIAN ANGELS GROUP HOME LLC CONTRACT NUMBER : 001022042 1 GUARDIAN ANGELS SERVICES APPLICANT CONTACT: JOSHUA N. KARIUKI PHONE: (469) 401-7301 FAX: (972) 234-4041 PHYSICAL ADDRESS : 426 BIRCH LANE, RICHARDSON, TX 75081 CONSUMERS ENROLLED IN THE FOLLOWING COUNTIES: NONE CONSUMERS ENROLLED STATEWIDE 3 ------------------------------------------------------------------------------ PROVIDER: 7GR GUIDING WAY HEALTHCARE LLC CONTRACT NUMBER : 001030601 GUIDING WAY HEALTHCARE LLC APPLICANT CONTACT: PAMELA STEGALL PHONE: (210) 929-8394 FAX: PHYSICAL ADDRESS : 6322 SOVEREIGN RD SUITE 235, SAN ANTONIO, TX 78229 CONSUMERS ENROLLED IN THE FOLLOWING COUNTIES: NONE CONSUMERS ENROLLED STATEWIDE 0 ------------------------------------------------------------------------------ PROVIDER: 82I HILL COUNTRY SAN ANTONIO MANAGEMENT INC CONTRACT NUMBER : 001008286 HILL COUNTRY SAN ANTONIO MANAGEMENT APPLICANT CONTACT: KELLY DENTON PHONE: (512) 589-3515 FAX: (512) 916-0607 PHYSICAL ADDRESS : FM 1626, MANCHACA, TX 78748 CONSUMERS ENROLLED IN THE FOLLOWING COUNTIES: BASTROP 6 BURNET 1 TRAVIS 17 WILLIAMSON 4 CONSUMERS ENROLLED STATEWIDE 167 ------------------------------------------------------------------------------ PROVIDER: 7D4 IMAGINE ART, INCORPORATED CONTRACT NUMBER : 001022046 IMAGINE ART, INCORPORATED APPLICANT CONTACT: KIZER DEBBIE PHONE: (512) 554-2406 FAX: (512) 448-1840 PHYSICAL ADDRESS : 2830 REAL STREET, AUSTIN, TX 78722 CONSUMERS ENROLLED IN THE FOLLOWING COUNTIES: TRAVIS 19 WILLIAMSON 1 CONSUMERS ENROLLED STATEWIDE 23 ------------------------------------------------------------------------------ PROVIDER: 7EQ INNOVATIVE STEPS CO CONTRACT NUMBER : 001029189 INNOVATIVE STEPS CO APPLICANT CONTACT: BRANDON DAVIS PHONE: (972) 821-9503 FAX: (940) 440-1301 PHYSICAL ADDRESS : 1509 COCKATIEL DRIVE, LITTLE ELM, TX 75068 CONSUMERS ENROLLED IN THE FOLLOWING COUNTIES: FREESTONE 1 CONSUMERS ENROLLED STATEWIDE 36 ------------------------------------------------------------------------------ PROVIDER: 7EJ INTEGRITY LIVING CENTER INC CONTRACT NUMBER : 001029203 INTEGRITY LIVING CENTER INC APPLICANT CONTACT: DAMILOLA KING PHONE: (909) 205-5146 FAX: (000) 000-0000 PHYSICAL ADDRESS : 7718 DEL GLEN LN, HOUSTON, TX 77072 DATE PREPARED: 03-21-20 H H S C REPORT NO.: HC062096 TIME PREPARED: 06:54 HCS PROGRAM PROVIDER INFORMATION PAGE : 37 WAIVER CONTRACT AREA: 6 MRA: 030 AUSTIN TRAVIS INTEGRAL CARE CONSUMERS ENROLLED IN THE FOLLOWING COUNTIES: NONE CONSUMERS ENROLLED STATEWIDE 5 ------------------------------------------------------------------------------ PROVIDER: 8QN ISSAC D EARLS CONTRACT NUMBER : 001008361 CONNECTING LIVES SERVICES APPLICANT CONTACT: ISSAC D. EARLS PHONE: (512) 947-7875 FAX: (512) 386-8180 PHYSICAL ADDRESS : 7901 CAMERON RD. BLDG. 2 STE. 219, AUSTIN, TX 78754 CONSUMERS ENROLLED IN THE FOLLOWING COUNTIES: BASTROP 3 BRAZOS 1 LEE 1 TRAVIS 29 WILLIAMSON 1 CONSUMERS ENROLLED STATEWIDE 36 ------------------------------------------------------------------------------ PROVIDER: 88V IVY REIGN SUPPORT SERVICES CONTRACT NUMBER : 001007980 IVY REIGN SUPPORT SERVICES APPLICANT CONTACT: TERRENCE TOLIVER PHONE: (254) 799-3900 FAX: (254) 799-3902 PHYSICAL ADDRESS : 2029 WASHINGTON AVE, WACO, TX 76701 CONSUMERS ENROLLED IN THE FOLLOWING COUNTIES: BELL 4 FALLS 4 FREESTONE 1 HILL 1 LAMPASAS 1 LIMESTONE 2 MCLENNAN 36 WILLIAMSON 1 CONSUMERS ENROLLED STATEWIDE 67 ------------------------------------------------------------------------------ PROVIDER: 7EH JAZMINE MARSHALL CONTRACT NUMBER : 001029224 JAZMINE MARSHALL APPLICANT CONTACT: JAZMINE MARSHALL PHONE: (281) 900-8625 FAX: (713) 692-2157 PHYSICAL ADDRESS : 9218 TRACELAWN CT, HUMBLE, TX 77396-1681 CONSUMERS ENROLLED IN THE FOLLOWING COUNTIES: NONE CONSUMERS ENROLLED STATEWIDE 3 ------------------------------------------------------------------------------ PROVIDER: 77C JBP HEALTH SEVICES INC CONTRACT NUMBER : 001029918 JBP HEALTH SEVICES INC APPLICANT CONTACT: DOMINICS VICTORIA PHONE: (713) 505-0111 FAX: (832) 201-9697 PHYSICAL ADDRESS : 19011 GOLDEN HEATH LN, RICHMOND, TX 77407-3817 CONSUMERS ENROLLED IN THE FOLLOWING COUNTIES: NONE CONSUMERS ENROLLED STATEWIDE 0 ------------------------------------------------------------------------------ PROVIDER: 8TM JOSEPH M OKORO CONTRACT NUMBER : 001008742 JOSEPH M. OKORO APPLICANT CONTACT: JOSEPH M. OKORO PHONE: (512) 785-3124 FAX: PHYSICAL ADDRESS : 10101 BLUFF BEND DRIVE, AUSTIN, TX 78753 CONSUMERS ENROLLED IN THE FOLLOWING COUNTIES: NONE CONSUMERS ENROLLED STATEWIDE 0 ------------------------------------------------------------------------------ PROVIDER: 8P7 KEISHA M. ROBINSON CONTRACT NUMBER : 001009175 QUALITY OF CARE SERVICES APPLICANT CONTACT: KEISHA ROBINSON PHONE: (281) 316-0640 FAX: (281) 316-0670 PHYSICAL ADDRESS : 1025 E. MAIN STREET,STE 103, LEAGUE CITY, TX 77573 CONSUMERS ENROLLED IN THE FOLLOWING COUNTIES: NONE CONSUMERS ENROLLED STATEWIDE 35 DATE PREPARED: 03-21-20 H H S C REPORT NO.: HC062096 TIME PREPARED: 06:54 HCS PROGRAM PROVIDER INFORMATION PAGE : 38 WAIVER CONTRACT AREA: 6 MRA: 030 AUSTIN TRAVIS INTEGRAL CARE ------------------------------------------------------------------------------ PROVIDER: 8CM KEITH MARTEL TAYLOR CONTRACT NUMBER : 001007374 KES CARE CENTER APPLICANT CONTACT: SHERYL P. HOSEA PHONE: (281) 847-1883 FAX: (281) 847-1845 PHYSICAL ADDRESS : 440 BENMAR #1225, HOUSTON, TX 77060 CONSUMERS ENROLLED IN THE FOLLOWING COUNTIES: NONE CONSUMERS ENROLLED STATEWIDE 0 ------------------------------------------------------------------------------ PROVIDER: 7GB KEMA CARE SERVICES INC CONTRACT NUMBER : 001030617 KEMA CARE SERVICES INC APPLICANT CONTACT: IKE ALARIBE PHONE: (832) 859-8777 FAX: (281) 596-4441 PHYSICAL ADDRESS : 5827 CRESTVIEW COVE, RICHMOND, TX 77469-6259 CONSUMERS ENROLLED IN THE FOLLOWING COUNTIES: NONE CONSUMERS ENROLLED STATEWIDE 0 ------------------------------------------------------------------------------ PROVIDER: 85D KENMAR RESIDENTIAL HCS SERVICES INC CONTRACT NUMBER : 001007619 KENMAR RESIDENTIAL HCS SERVICES INC APPLICANT CONTACT: JANET SIMONEAU PHONE: (512) 334-9192 FAX: (512) 334-9978 PHYSICAL ADDRESS : 555 ROUND ROCK WEST SUITE F360, ROUND ROCK, TX 78681 CONSUMERS ENROLLED IN THE FOLLOWING COUNTIES: BASTROP 4 BURNET 1 FAYETTE 2 GONZALES 3 LEE 3 TRAVIS 40 WILLIAMSON 75 CONSUMERS ENROLLED STATEWIDE 128 ------------------------------------------------------------------------------ PROVIDER: 7GQ KES CARE LEARNING AND DEVELOPM CONTRACT NUMBER : 001030580 KES CARE LEARNING AND DEVELOPMENT CENTER APPLICANT CONTACT: SHERYL HOSEA PHONE: (713) 673-2000 FAX: (713) 673-2007 PHYSICAL ADDRESS : 1621 PLEASANTVILLE DRVIE, HOUSTON, TX 77029 CONSUMERS ENROLLED IN THE FOLLOWING COUNTIES: NONE CONSUMERS ENROLLED STATEWIDE 17 ------------------------------------------------------------------------------ PROVIDER: 7EG LASHABRIA R EVANS CONTRACT NUMBER : 001028941 LASHABRIA R EVANS APPLICANT CONTACT: LASHABRIA EVANS PHONE: (214) 402-6024 FAX: (972) 730-9404 PHYSICAL ADDRESS : 2825 N. STATE HWY 360 APT 214, GRAND PRAIRIE, TX 75050 CONSUMERS ENROLLED IN THE FOLLOWING COUNTIES: NONE CONSUMERS ENROLLED STATEWIDE 23 ------------------------------------------------------------------------------ PROVIDER: 87B LIFE CHOICES UNLIMITED, INC. CONTRACT NUMBER : 001008678 LIFE CHOICES UNLIMITED,INC. APPLICANT CONTACT: SERGIO CASTILLO PHONE: (888) 316-4506 FAX: (877) 316-4608 PHYSICAL ADDRESS : 608 S. JACKSON RD., EDINBURG, TX 78539 CONSUMERS ENROLLED IN THE FOLLOWING COUNTIES: TRAVIS 1 CONSUMERS ENROLLED STATEWIDE 175 ------------------------------------------------------------------------------ PROVIDER: 8QX LIFETIME LIVING INC CONTRACT NUMBER : 001008427 LIFETIME LIVING, INC APPLICANT CONTACT: DALINDA DANIELS PHONE: (210) 651-0279 FAX: (210) 651-4579 DATE PREPARED: 03-21-20 H H S C REPORT NO.: HC062096 TIME PREPARED: 06:54 HCS PROGRAM PROVIDER INFORMATION PAGE : 39 WAIVER CONTRACT AREA: 6 MRA: 030 AUSTIN TRAVIS INTEGRAL CARE PHYSICAL ADDRESS : 5425 N LOOP 1604 E, SAN ANTONIO, TX 78247 CONSUMERS ENROLLED IN THE FOLLOWING COUNTIES: BELL 2 GONZALES 1 GUADALUPE 32 TRAVIS 3 WILLIAMSON 1 CONSUMERS ENROLLED STATEWIDE 662 ------------------------------------------------------------------------------ PROVIDER: 8ZW LIVINGMIND PROJECT INCORPORATE CONTRACT NUMBER : 001009552 LIVINGMIND PROJECT INCORPORATE APPLICANT CONTACT: NWOJO SAMUEL PHONE: (281) 293-9200 FAX: (281) 293-9203 PHYSICAL ADDRESS : 16205 WESTHEIMER ROAD, SUITE 100, HOUSTON, TX 77082 CONSUMERS ENROLLED IN THE FOLLOWING COUNTIES: NONE CONSUMERS ENROLLED STATEWIDE 27 ------------------------------------------------------------------------------ PROVIDER: 8SY LIVINUS UGO ONWUEGBU CONTRACT NUMBER : 001029827 LIVINUS UGO ONWUEGBU APPLICANT CONTACT: LIVINUS ONWUEGBU PHONE: (713) 498-3142 FAX: (281) 617-7479 PHYSICAL ADDRESS : 7519 TIMBERWAY LN, HOUSTON, TX 77072 CONSUMERS ENROLLED IN THE FOLLOWING COUNTIES: NONE CONSUMERS ENROLLED STATEWIDE 3 ------------------------------------------------------------------------------ PROVIDER: 8BG LUCKY HEALTH CARE SERVICES INC. CONTRACT NUMBER : 001007375 LUCKY HEALTH CARE SERVICES INC. APPLICANT CONTACT: DANIEL OSUAGWU PHONE: (713) 773-1066 FAX: (713) 773-0445 PHYSICAL ADDRESS : 10103 FONDREN, SUITE 460, HOUSTON, TX 77096 CONSUMERS ENROLLED IN THE FOLLOWING COUNTIES: NONE CONSUMERS ENROLLED STATEWIDE 10 ------------------------------------------------------------------------------ PROVIDER: 8SQ MAOFU HOME HEALTH CARE SERVICE CONTRACT NUMBER : 001008607 MAOFU HOME HEALTH CARE SERVICES, IN APPLICANT CONTACT: LUCAS TAMBE PHONE: (512) 506-0459 FAX: (737) 484-8272 PHYSICAL ADDRESS : 7901 CAMERON ROAD, BLDG 3 SUITE 139, AUSTIN, TX 78754 CONSUMERS ENROLLED IN THE FOLLOWING COUNTIES: BELL 3 TRAVIS 60 WILLIAMSON 11 CONSUMERS ENROLLED STATEWIDE 108 ------------------------------------------------------------------------------ PROVIDER: 8B2 MARK I RESIDENTIAL SERVICES INC CONTRACT NUMBER : 001007376 MARK I RESIDENTIAL SERVICES INC. APPLICANT CONTACT: MARK HENSON PHONE: (512) 789-4079 FAX: (512) 448-0966 PHYSICAL ADDRESS : 7804 CREEKMERE DR., AUSTIN, TX 78748 CONSUMERS ENROLLED IN THE FOLLOWING COUNTIES: TRAVIS 20 CONSUMERS ENROLLED STATEWIDE 20 ------------------------------------------------------------------------------ PROVIDER: 8CR MARY LEE FOUNDATION CONTRACT NUMBER : 001007378 MARY LEE FOUNDATION-SOUTHPOINTE APPLICANT CONTACT: LEIGH DUNSON, PHONE: (512) 442-6077 FAX: (512) 442-6825 PHYSICAL ADDRESS : 1336 LAMAR SQUARE DRIVE, AUSTIN, TX 78704 CONSUMERS ENROLLED IN THE FOLLOWING COUNTIES: TRAVIS 71 CONSUMERS ENROLLED STATEWIDE 95 DATE PREPARED: 03-21-20 H H S C REPORT NO.: HC062096 TIME PREPARED: 06:54 HCS PROGRAM PROVIDER INFORMATION PAGE : 40 WAIVER CONTRACT AREA: 6 MRA: 030 AUSTIN TRAVIS INTEGRAL CARE ------------------------------------------------------------------------------ PROVIDER: 87S MOSAIC CONTRACT NUMBER : 001007906 MOSAIC APPLICANT CONTACT: JENNIFFER LEDOUX PHONE: (281) 257-5430 FAX: (844) 272-0258 PHYSICAL ADDRESS : 17207 KUYKENDAHL STE 220, SPRING, TX 77379-0000 CONSUMERS ENROLLED IN THE FOLLOWING COUNTIES: NONE CONSUMERS ENROLLED STATEWIDE 0 ------------------------------------------------------------------------------ PROVIDER: 7FD NENEH BAH CONTRACT NUMBER : 001029761 NENEH BAH APPLICANT CONTACT: NENEH BAH PHONE: (903) 917-8027 FAX: (000) 000-0000 PHYSICAL ADDRESS : 2000 E LAMAR BLVD_SUITE 600, ARLINGTON, TX 76006 CONSUMERS ENROLLED IN THE FOLLOWING COUNTIES: NONE CONSUMERS ENROLLED STATEWIDE 7 ------------------------------------------------------------------------------ PROVIDER: 844 NEWSTART HCS, INC. CONTRACT NUMBER : 001008401 HCS OF NORTH TEXAS APPLICANT CONTACT: ANNE SETTLE PHONE: (817) 294-9675 FAX: (817) 294-9907 PHYSICAL ADDRESS : 2755 ALTA MESA, FORT WORTH, TX 76133 CONSUMERS ENROLLED IN THE FOLLOWING COUNTIES: NONE CONSUMERS ENROLLED STATEWIDE 66 ------------------------------------------------------------------------------ PROVIDER: 8YC NKEIRU PRISCA UCHEM CONTRACT NUMBER : 001022099 GRACEFUL CARE CENTER APPLICANT CONTACT: NKEIRU PRISCA, UCHE PHONE: (832) 607-5664 FAX: (281) 498-9935 PHYSICAL ADDRESS : 14922 HAVENRIDGE DR., HOUSTON, TX 77083 CONSUMERS ENROLLED IN THE FOLLOWING COUNTIES: NONE CONSUMERS ENROLLED STATEWIDE 2 ------------------------------------------------------------------------------ PROVIDER: 7D1 N2 CARE SERVICES INC CONTRACT NUMBER : 001021989 N2 CARE SERVICES INC APPLICANT CONTACT: IKE ALARIBE PHONE: (832) 859-8777 FAX: (281) 239-6364 PHYSICAL ADDRESS : 5827 CRESTVIEW COVE, RICHMOND, TX 77469 CONSUMERS ENROLLED IN THE FOLLOWING COUNTIES: WILLIAMSON 1 CONSUMERS ENROLLED STATEWIDE 11 ------------------------------------------------------------------------------ PROVIDER: 7ES ODYSSEY STABILITY SUPPORT SERV CONTRACT NUMBER : 001029625 ODYSSEY STABILITY SUPPORT SERVICES INC APPLICANT CONTACT: DIMITRA SMITH PHONE: (281) 787-1429 FAX: (281) 784-1010 PHYSICAL ADDRESS : 220 N VISTA DR, HOUSTON, TX 77073 CONSUMERS ENROLLED IN THE FOLLOWING COUNTIES: NONE CONSUMERS ENROLLED STATEWIDE 12 ------------------------------------------------------------------------------ PROVIDER: 8NY OLUGBENGA AJALA CONTRACT NUMBER : 001008703 BAYOU HEALTH CARE APPLICANT CONTACT: OLUGBENGA AJALA PHONE: (713) 270-6203 FAX: (713) 270-6207 PHYSICAL ADDRESS : 10039 BISSONENT ST,STE 219, HOUSTON, TX 77489 DATE PREPARED: 03-21-20 H H S C REPORT NO.: HC062096 TIME PREPARED: 06:54 HCS PROGRAM PROVIDER INFORMATION PAGE : 41 WAIVER CONTRACT AREA: 6 MRA: 030 AUSTIN TRAVIS INTEGRAL CARE CONSUMERS ENROLLED IN THE FOLLOWING COUNTIES: TRAVIS 1 CONSUMERS ENROLLED STATEWIDE 11 ------------------------------------------------------------------------------ PROVIDER: 8US PEPPERTREE COMPLETE CARE LLC CONTRACT NUMBER : 001021901 PEPPERTREE COMPLETE CARE LLC APPLICANT CONTACT: KINA JEFFERSON PHONE: (832) 527-6750 FAX: PHYSICAL ADDRESS : 11818 LONGWOOD GARDEN WAY, HOUSTON, TX 77047 CONSUMERS ENROLLED IN THE FOLLOWING COUNTIES: NONE CONSUMERS ENROLLED STATEWIDE 3 ------------------------------------------------------------------------------ PROVIDER: 7B7 PHILOMENA EKWEALOR CONTRACT NUMBER : 001022113 DBA REAL COMFORT LIVING APPLICANT CONTACT: PHILOMENA EKWEALOR PHONE: (281) 300-8765 FAX: (281) 437-6622 PHYSICAL ADDRESS : 1138 TURTLE CREEK DR, MISSOURI CITY, TX 77489 CONSUMERS ENROLLED IN THE FOLLOWING COUNTIES: NONE CONSUMERS ENROLLED STATEWIDE 14 ------------------------------------------------------------------------------ PROVIDER: 7GU PHOEBE ACOSTA RUIZ CONTRACT NUMBER : 001030809 PHOEBE ACOSTA RUIZ APPLICANT CONTACT: PHOEBE A. RUIZ PHONE: (713) 885-2667 FAX: (281) 661-1666 PHYSICAL ADDRESS : 15434 W WILLOWWIND CIR, HOUSTON, TX 77071 CONSUMERS ENROLLED IN THE FOLLOWING COUNTIES: NONE CONSUMERS ENROLLED STATEWIDE 0 ------------------------------------------------------------------------------ PROVIDER: 808 PREMIEANT INCORPORATED CONTRACT NUMBER : 001007388 PREMIEANT INCORPORATED APPLICANT CONTACT: JEFF ENGELKE PHONE: (512) 916-1632 FAX: (512) 916-1639 PHYSICAL ADDRESS : 1110 W. WILLIAM CANNON BLDG 2, AUSTIN, TX 78745 CONSUMERS ENROLLED IN THE FOLLOWING COUNTIES: TRAVIS 35 CONSUMERS ENROLLED STATEWIDE 289 ------------------------------------------------------------------------------ PROVIDER: 7FC QUESTCARE HEALTH AND COMMUNITY CONTRACT NUMBER : 001029711 QUESTCARE HEALTH AND COMMUNITY SERVICES APPLICANT CONTACT: TOJUNA ELDRIDGE PHONE: (281) 746-5823 FAX: (281) 417-0029 PHYSICAL ADDRESS : 1918 FREEMAN STREET, HOUSTON, TX 77009 CONSUMERS ENROLLED IN THE FOLLOWING COUNTIES: NONE CONSUMERS ENROLLED STATEWIDE 1 ------------------------------------------------------------------------------ PROVIDER: 7D7 RACHEAL BRANCH CONTRACT NUMBER : 001022074 APPROVED HEALTHCARE APPLICANT CONTACT: RACHEAL BRANCH PHONE: (832) 515-8778 FAX: PHYSICAL ADDRESS : 233 BLUE HILL DRIVE, MONTGOMERY, TX 77356 CONSUMERS ENROLLED IN THE FOLLOWING COUNTIES: NONE CONSUMERS ENROLLED STATEWIDE 1 ------------------------------------------------------------------------------ PROVIDER: 8CD REACHING MAXIMUM INDEPENDENCE, INC. DATE PREPARED: 03-21-20 H H S C REPORT NO.: HC062096 TIME PREPARED: 06:54 HCS PROGRAM PROVIDER INFORMATION PAGE : 42 WAIVER CONTRACT AREA: 6 MRA: 030 AUSTIN TRAVIS INTEGRAL CARE CONTRACT NUMBER : 001009017 REACHING MAXIMUM INDEPENDENCE APPLICANT CONTACT: SARA RIDEOUT PHONE: (210) 656-6674 FAX: (210) 656-0199 PHYSICAL ADDRESS : 6336 MONTGOMERY, SAN ANTONIO, TX 78239 CONSUMERS ENROLLED IN THE FOLLOWING COUNTIES: NONE CONSUMERS ENROLLED STATEWIDE 56 ------------------------------------------------------------------------------ PROVIDER: 8YH ROBERT S MORRIS CONTRACT NUMBER : 001009381 REGENCY CARE HOME APPLICANT CONTACT: ROBERT MORRIS PHONE: (512) 784-8687 FAX: PHYSICAL ADDRESS : 555 ROUND ROCK WEST, BLDG E STE 203, ROUND ROCK, TX 78681 CONSUMERS ENROLLED IN THE FOLLOWING COUNTIES: BASTROP 2 BURNET 2 TRAVIS 11 WILLIAMSON 19 CONSUMERS ENROLLED STATEWIDE 34 ------------------------------------------------------------------------------ PROVIDER: 856 ROCK HOUSE SUPPORT SERVICES, INC. CONTRACT NUMBER : 001007392 ROCK HOUSE SUPPORT SERVICES APPLICANT CONTACT: MICHELLE WRIGHT PHONE: (512) 863-7968 FAX: (512) 869-2176 PHYSICAL ADDRESS : 6920 WILLIAMS DR, GEORGETOWN, TX 78633 CONSUMERS ENROLLED IN THE FOLLOWING COUNTIES: WILLIAMSON 54 CONSUMERS ENROLLED STATEWIDE 376 ------------------------------------------------------------------------------ PROVIDER: 79J ROSY IN HOME SERVICES INC CONTRACT NUMBER : 001021453 ROSY IN HOME SERVICES, INC. APPLICANT CONTACT: UZUH ROSEMARY PHONE: (512) 479-1820 FAX: (512) 719-0908 PHYSICAL ADDRESS : 3724 AIRPORT BLVD., AUSTIN, TX 78722 CONSUMERS ENROLLED IN THE FOLLOWING COUNTIES: NONE CONSUMERS ENROLLED STATEWIDE 0 ------------------------------------------------------------------------------ PROVIDER: 8Z1 S&E ENTERPRISE LLC CONTRACT NUMBER : 001009418 S&E ENTERPRISE LLC APPLICANT CONTACT: SEDALIA RICE PHONE: (832) 203-7880 FAX: (832) 581-3335 PHYSICAL ADDRESS : 13831 NORTHWEST FREEWAY SUITE 180, HOUSTON, TX 77040 CONSUMERS ENROLLED IN THE FOLLOWING COUNTIES: NONE CONSUMERS ENROLLED STATEWIDE 29 ------------------------------------------------------------------------------ PROVIDER: 7E6 SAMLIZY HCS AND TXHML SERVICE CONTRACT NUMBER : 001029266 SAMLIZY HCS AND TXHML SERVICES INC APPLICANT CONTACT: CHINONSO ADIMIBE PHONE: (832) 620-7018 FAX: (000) 000-0000 PHYSICAL ADDRESS : 10022 HALSTON DRIVE, SUGARLAND, TX 77498 CONSUMERS ENROLLED IN THE FOLLOWING COUNTIES: NONE CONSUMERS ENROLLED STATEWIDE 0 ------------------------------------------------------------------------------ PROVIDER: 879 SANDRA CORNELIUS CONTRACT NUMBER : 001007957 SANDRA CORNELIUS APPLICANT CONTACT: SANDRA CORNELIUS PHONE: (713) 598-2424 FAX: (713) 365-9581 PHYSICAL ADDRESS : 2804 HOLLY HALL, HOUSTON, TX 77054 CONSUMERS ENROLLED IN THE FOLLOWING COUNTIES: NONE DATE PREPARED: 03-21-20 H H S C REPORT NO.: HC062096 TIME PREPARED: 06:54 HCS PROGRAM PROVIDER INFORMATION PAGE : 43 WAIVER CONTRACT AREA: 6 MRA: 030 AUSTIN TRAVIS INTEGRAL CARE CONSUMERS ENROLLED STATEWIDE 3 ------------------------------------------------------------------------------ PROVIDER: 7ET SARAH ALEXANDER SOTO CONTRACT NUMBER : 001029369 SARAH ALEXANDER SOTO APPLICANT CONTACT: SARAH SOTO PHONE: (832) 797-1235 FAX: (936) 647-4747 PHYSICAL ADDRESS : 142 SILVERPENNY DR, CONROE, TX 77384 CONSUMERS ENROLLED IN THE FOLLOWING COUNTIES: NONE CONSUMERS ENROLLED STATEWIDE 4 ------------------------------------------------------------------------------ PROVIDER: 7DB SHAREL SULLIVAN CONTRACT NUMBER : 001022020 THE HARMONY PLACE HOME APPLICANT CONTACT: SULLIVAN SHAREL PHONE: (972) 698-7600 FAX: (972) 698-0838 PHYSICAL ADDRESS : 12248 CHINA LAKE DR, DALLAS, TX 75253 CONSUMERS ENROLLED IN THE FOLLOWING COUNTIES: NONE CONSUMERS ENROLLED STATEWIDE 39 ------------------------------------------------------------------------------ PROVIDER: 7FR SONYA GOLDEN CONTRACT NUMBER : 001029584 SONYA GOLDEN APPLICANT CONTACT: GOLDEN SONYA PHONE: (469) 563-9068 FAX: (817) 945-2868 PHYSICAL ADDRESS : 7951 CHARLESTOWN LN, FORT WORTH, TX 76140-8642 CONSUMERS ENROLLED IN THE FOLLOWING COUNTIES: NONE CONSUMERS ENROLLED STATEWIDE 21 ------------------------------------------------------------------------------ PROVIDER: 8QU SPLENDOR HILLS INCORPORATED CONTRACT NUMBER : 001022082 SPLENDOR HILLS RESIDENTIAL SERVICES APPLICANT CONTACT: EDOLOROSE AZENABOR PHONE: (214) 418-8240 FAX: (972) 262-6544 PHYSICAL ADDRESS : 2306 OAK LANE, SUITE 202, GRAND PRAIRIE, TX 75051 CONSUMERS ENROLLED IN THE FOLLOWING COUNTIES: NONE CONSUMERS ENROLLED STATEWIDE 0 ------------------------------------------------------------------------------ PROVIDER: 7DA STEPHENS COMMUNITY LIVING HCS CONTRACT NUMBER : 001022106 STEPHENS COMMUNITY LIVING HCS APPLICANT CONTACT: FELICIA NASH PHONE: (469) 274-2828 FAX: (469) 297-5903 PHYSICAL ADDRESS : 1035 HUNTERS CREEK DR, DESOTO, TX 75115-4712 CONSUMERS ENROLLED IN THE FOLLOWING COUNTIES: NONE CONSUMERS ENROLLED STATEWIDE 12 ------------------------------------------------------------------------------ PROVIDER: 8UI SUPPORTING FAMILIES FIRST LLC CONTRACT NUMBER : 001021796 SUPPORTING FAMILIES FIRST LLC APPLICANT CONTACT: LENNE BRYANT PHONE: (832) 368-7665 FAX: (832) 218-2872 PHYSICAL ADDRESS : 19502 GABLE CROSSING DRIVE, RICHMOND, TX 77407 CONSUMERS ENROLLED IN THE FOLLOWING COUNTIES: TRAVIS 1 CONSUMERS ENROLLED STATEWIDE 16 ------------------------------------------------------------------------------ PROVIDER: 7CX TAB INTERNATIONAL INC CONTRACT NUMBER : 001021973 TAB INTERNATIONAL INC DATE PREPARED: 03-21-20 H H S C REPORT NO.: HC062096 TIME PREPARED: 06:54 HCS PROGRAM PROVIDER INFORMATION PAGE : 44 WAIVER CONTRACT AREA: 6 MRA: 030 AUSTIN TRAVIS INTEGRAL CARE APPLICANT CONTACT: BALOGUN ABAYOMI PHONE: (713) 772-2726 FAX: (713) 981-1990 PHYSICAL ADDRESS : 10101 FONDREN ROAD STE 428, HOUSTON, TX 77096 CONSUMERS ENROLLED IN THE FOLLOWING COUNTIES: NONE CONSUMERS ENROLLED STATEWIDE 0 ------------------------------------------------------------------------------ PROVIDER: 7DY TGI BROOKSTREET INC CONTRACT NUMBER : 001022123 TGI BROOKSTREET INC APPLICANT CONTACT: OLUMIDE ADEBOWALE PHONE: (832) 491-7578 FAX: (281) 674-8985 PHYSICAL ADDRESS : 114 E ALAMO ST SUITE 33, BRENHAM, TX 77833 CONSUMERS ENROLLED IN THE FOLLOWING COUNTIES: NONE CONSUMERS ENROLLED STATEWIDE 12 ------------------------------------------------------------------------------ PROVIDER: 83E THOMAS AND LEWIN ASSOCIATES, INC. CONTRACT NUMBER : 001007403 QUALITY CARE COMMUNITY SEVICES APPLICANT CONTACT: ATHENA THOMAS PHONE: (281) 679-1309 FAX: (281) 633-8014 PHYSICAL ADDRESS : 2025 AVENUE G, ROSENBERG, TX 77471 CONSUMERS ENROLLED IN THE FOLLOWING COUNTIES: WASHINGTON 8 CONSUMERS ENROLLED STATEWIDE 65 ------------------------------------------------------------------------------ PROVIDER: 8ZD THREE B'S HEALTH SOLUTIONS INC CONTRACT NUMBER : 001022081 THREE B'S ASSISTED LIVING APPLICANT CONTACT: PATRICIA AMAEFULE PHONE: (713) 776-9996 FAX: (888) 202-1988 PHYSICAL ADDRESS : 9800 CENTRE PARKWAY SUITE 260A, HOUSTON, TX 77036 CONSUMERS ENROLLED IN THE FOLLOWING COUNTIES: NONE CONSUMERS ENROLLED STATEWIDE 3 ------------------------------------------------------------------------------ PROVIDER: 7DU TIANA JEANETTE SCOGGINS CONTRACT NUMBER : 001022110 1ST CHOICE HOMES APPLICANT CONTACT: SCOGGINS TIANA PHONE: (832) 704-5783 FAX: (832) 202-2874 PHYSICAL ADDRESS : 4535 COUNTRYCROSSING DR, SPRING, TX 77388 CONSUMERS ENROLLED IN THE FOLLOWING COUNTIES: NONE CONSUMERS ENROLLED STATEWIDE 31 ------------------------------------------------------------------------------ PROVIDER: 7DW TOTAL CARE HOME HEALTH INC CONTRACT NUMBER : 001022118 TOTAL CARE HOME HEALTH INC APPLICANT CONTACT: ELIZABETH HALLMOTEN PHONE: (512) 367-9049 FAX: (512) 727-9209 PHYSICAL ADDRESS : 8061 MOZART STREET, ROUND ROCK, TX 78665 CONSUMERS ENROLLED IN THE FOLLOWING COUNTIES: BELL 5 MCLENNAN 2 TRAVIS 1 WILLIAMSON 10 CONSUMERS ENROLLED STATEWIDE 19 ------------------------------------------------------------------------------ PROVIDER: 7EU TOTAL FRIENDLY CARE SERVICES I CONTRACT NUMBER : 001029444 TOTAL FRIENDLY CARE SERVICES INC APPLICANT CONTACT: JULIE OBI PHONE: (832) 767-3605 FAX: (832) 767-3626 PHYSICAL ADDRESS : 6776 SOUTHWEST FREEWAY STE 272, HOUSTON, TX 77074 CONSUMERS ENROLLED IN THE FOLLOWING COUNTIES: NONE CONSUMERS ENROLLED STATEWIDE 22 DATE PREPARED: 03-21-20 H H S C REPORT NO.: HC062096 TIME PREPARED: 06:54 HCS PROGRAM PROVIDER INFORMATION PAGE : 45 WAIVER CONTRACT AREA: 6 MRA: 030 AUSTIN TRAVIS INTEGRAL CARE ------------------------------------------------------------------------------ PROVIDER: 77N VERICON HEALTH RESOURCES LLC CONTRACT NUMBER : 001021508 VERICON HEALTH RESOURCES LLC APPLICANT CONTACT: JORFUI K DABO PHONE: (281) 762-1726 FAX: (281) 762-1727 PHYSICAL ADDRESS : 5202 EMORY MILL RD, RICHMOND, TX 77407 CONSUMERS ENROLLED IN THE FOLLOWING COUNTIES: NONE CONSUMERS ENROLLED STATEWIDE 8 ------------------------------------------------------------------------------ PROVIDER: 83C VIRGINIA R THURMAN CONTRACT NUMBER : 001007405 CLYDIES PLACE APPLICANT CONTACT: VIRGINIA R. THURMAN PHONE: (903) 855-0845 FAX: (903) 855-0899 PHYSICAL ADDRESS : 424 HENDERSON STREET, PITTSBURG, TX 75686 CONSUMERS ENROLLED IN THE FOLLOWING COUNTIES: BELL 3 CORYELL 2 CONSUMERS ENROLLED STATEWIDE 18 ------------------------------------------------------------------------------ PROVIDER: 7GH VIRTUES OF LOVE PLACE LLC CONTRACT NUMBER : 001030305 VIRTUES OF LOVE PLACE LLC APPLICANT CONTACT: AGATHA SHIPMAN PHONE: (301) 213-6728 FAX: PHYSICAL ADDRESS : 1003 OAKRIDGE ST, BRENHAM, TX 77833 CONSUMERS ENROLLED IN THE FOLLOWING COUNTIES: NONE CONSUMERS ENROLLED STATEWIDE 0 ------------------------------------------------------------------------------ PROVIDER: 8WU WILDA DEAN ODUM ROY CONTRACT NUMBER : 001009186 CARING DISABILITY PROVIDER APPLICANT CONTACT: WILDA ROY PHONE: (469) 556-9933 FAX: (972) 625-6881 PHYSICAL ADDRESS : 5044 LAKE VISTA DRIVE, THE COLONY, TX 75056 CONSUMERS ENROLLED IN THE FOLLOWING COUNTIES: NONE CONSUMERS ENROLLED STATEWIDE 14 ------------------------------------------------------------------------------ PROVIDER: 7EN YOS HEALTH CARE SERVICES INC CONTRACT NUMBER : 001029285 YOS HEALTH CARE SERVICES INC APPLICANT CONTACT: EMMANUEL SOFELA PHONE: (866) 900-5007 FAX: (866) 677-1896 PHYSICAL ADDRESS : 34 BRYCE BRANCH CIR, WOODLANDS, TX 77382 CONSUMERS ENROLLED IN THE FOLLOWING COUNTIES: NONE CONSUMERS ENROLLED STATEWIDE 0 ------------------------------------------------------------------------------ PROVIDER: 79G 1 ON 1 KF HOMES, INC. CONTRACT NUMBER : 001021445 1 ON 1 KF HOMES, INC. APPLICANT CONTACT: WARREN ANGELA PHONE: (713) 272-7226 FAX: (713) 272-7238 PHYSICAL ADDRESS : 9888 BISSONNET STREET, STE. 350, HOUSTON, TX 77036 CONSUMERS ENROLLED IN THE FOLLOWING COUNTIES: MCLENNAN 1 CONSUMERS ENROLLED STATEWIDE 148 TOTAL NUMBER OF CONTRACTS THIS MRA: 135 DATE PREPARED: 03-21-20 H H S C REPORT NO.: HC062096 TIME PREPARED: 06:54 HCS PROGRAM PROVIDER INFORMATION PAGE : 46 WAIVER CONTRACT AREA: 6 MRA: 030 AUSTIN TRAVIS INTEGRAL CARE