DATE PREPARED: 01-09-21 H H S C REPORT NO.: HC062097 TIME PREPARED: 06:47 TXHML PROGRAM PROVIDER INFORMATION PAGE : 14 WAIVER CONTRACT AREA: 6 MRA: 030 AUSTIN TRAVIS INTEGRAL CARE ------------------------------------------------------------------------------ PROVIDER: 76R A BETTER HCS HOME INC CONTRACT NUMBER : 001011641 A BETTER HCS HOME INC APPLICANT CONTACT: DARCY BENFORD PHONE: (254) 498-9361 FAX: (254) 662-9121 PHYSICAL ADDRESS : 625 BRUSHY CREEK, HEWITT, TX 76643 SERVICE(S) PROVIDED BY PROGRAM PROVIDER EMPLOYEES ONLY* : DH SE RE CS CFPH CONSUMERS ENROLLED IN THE FOLLOWING COUNTIES: BELL 7 HILL 1 MCLENNAN 16 CONSUMERS ENROLLED STATEWIDE 41 ------------------------------------------------------------------------------ PROVIDER: 79E A FAIR CHOICE, INC. CONTRACT NUMBER : 001011940 A FAIR CHOICE, INC. APPLICANT CONTACT: KRISTY LEDESMA PHONE: (817) 320-6836 FAX: (817) 200-7572 PHYSICAL ADDRESS : PO BOX 152034, ARLINGTON, TX 76015 SERVICE(S) PROVIDED BY PROGRAM PROVIDER EMPLOYEES ONLY* : DH SE RE CS CFPH CONSUMERS ENROLLED IN THE FOLLOWING COUNTIES: WILLIAMSON 1 CONSUMERS ENROLLED STATEWIDE 38 ------------------------------------------------------------------------------ PROVIDER: 8XA A FAMILY OF NEW BEGINNINGS INC CONTRACT NUMBER : 001011104 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 SERVICE(S) PROVIDED BY PROGRAM PROVIDER EMPLOYEES ONLY* : DH CONSUMERS ENROLLED IN THE FOLLOWING COUNTIES: TRAVIS 4 WILLIAMSON 1 CONSUMERS ENROLLED STATEWIDE 45 ------------------------------------------------------------------------------ PROVIDER: 7CY A MEANING OF LIFE LLC CONTRACT NUMBER : 001031367 A MEANING OF LIFE LLC APPLICANT CONTACT: JESSICA VIRGIL PHONE: (682) 224-6218 FAX: (817) 887-4157 PHYSICAL ADDRESS : 1322 NW JOHN JONES DRIVE, BURLESON, TX 76028 SERVICE(S) PROVIDED BY PROGRAM PROVIDER EMPLOYEES ONLY* : DH SE RE CS CFPH CONSUMERS ENROLLED IN THE FOLLOWING COUNTIES: NONE CONSUMERS ENROLLED STATEWIDE 84 ------------------------------------------------------------------------------ PROVIDER: 8XC A TAP INC CONTRACT NUMBER : 001011109 A TAP INC APPLICANT CONTACT: TONY ALEXANDER PHONE: (281) 433-6529 FAX: (832) 360-2768 PHYSICAL ADDRESS : 9118 MESA DRIVE, HOUSTON, TX 77028 SERVICE(S) PROVIDED BY PROGRAM PROVIDER EMPLOYEES ONLY* : CS CFPH CONSUMERS ENROLLED IN THE FOLLOWING COUNTIES: NONE CONSUMERS ENROLLED STATEWIDE 44 ------------------------------------------------------------------------------ PROVIDER: 79X A TOP LINE CHOICE INC CONTRACT NUMBER : 001023805 A TOP LINE CHOICE INC APPLICANT CONTACT: KAREN NAPPIER PHONE: (817) 307-2491 FAX: (817) 200-7572 PHYSICAL ADDRESS : 6705 KEELER DR, ARLINGTON, TX 76001 SERVICE(S) PROVIDED BY PROGRAM PROVIDER EMPLOYEES ONLY* : DH SE RE CS CFPH * DH-DAY HAB, SE-SUPORRTED EMP, RE-RESPITE, CS-COMMUNITY SUPPORT DATE PREPARED: 01-09-21 H H S C REPORT NO.: HC062097 TIME PREPARED: 06:47 TXHML PROGRAM PROVIDER INFORMATION PAGE : 15 WAIVER CONTRACT AREA: 6 MRA: 030 AUSTIN TRAVIS INTEGRAL CARE CONSUMERS ENROLLED IN THE FOLLOWING COUNTIES: NONE CONSUMERS ENROLLED STATEWIDE 8 ------------------------------------------------------------------------------ PROVIDER: 7FJ AGRICH HEALTH SERVICE LLC CONTRACT NUMBER : 001029782 AGRICH HEALTH SERVICE LLC APPLICANT CONTACT: ANYIGBO FRANCES PHONE: (832) 444-3714 FAX: (832) 945-3977 PHYSICAL ADDRESS : 7738 DEEP GREEN DRIVE, ROSENBERG, TX 77469-4672 SERVICE(S) PROVIDED BY PROGRAM PROVIDER EMPLOYEES ONLY* : DH SE RE CS CFPH CONSUMERS ENROLLED IN THE FOLLOWING COUNTIES: NONE CONSUMERS ENROLLED STATEWIDE 1 ------------------------------------------------------------------------------ PROVIDER: 8YM AHORA Y SIEMPRE INC CONTRACT NUMBER : 001011452 AHORA Y SIEMPRE INC APPLICANT CONTACT: FRANCISCO GONZALEZ PHONE: (214) 741-6359 FAX: (214) 741-6389 PHYSICAL ADDRESS : 1412 MAIN STREET STE 205, DALLAS, TX 75202 SERVICE(S) PROVIDED BY PROGRAM PROVIDER EMPLOYEES ONLY* : RE CS CFPH CONSUMERS ENROLLED IN THE FOLLOWING COUNTIES: BELL 24 GONZALES 1 LAMPASAS 1 MILAM 1 WILLIAMSON 1 CONSUMERS ENROLLED STATEWIDE 363 ------------------------------------------------------------------------------ PROVIDER: 87P AMAZING GRACE HEALTHCARE SERVICES, INC. CONTRACT NUMBER : 001010429 AMAZING GRACE HEALTHCARE SERVICES, APPLICANT CONTACT: MICHAEL OKPAMEN PHONE: (281) 827-2081 FAX: (281) 499-0407 PHYSICAL ADDRESS : 620 FM 1092 MURPHY ROAD #105, STAFFORD, TX 77477 SERVICE(S) PROVIDED BY PROGRAM PROVIDER EMPLOYEES ONLY* : DH CS CFPH CONSUMERS ENROLLED IN THE FOLLOWING COUNTIES: MCLENNAN 1 CONSUMERS ENROLLED STATEWIDE 16 ------------------------------------------------------------------------------ PROVIDER: 7BA ANDREW M CONTRERAS III CONTRACT NUMBER : 001023897 MIRCLES HAPPEN APPLICANT CONTACT: CONTRERAS I ANDREW PHONE: (210) 491-4419 FAX: (210) 491-5244 PHYSICAL ADDRESS : 2881 THOUSAND OAKS, SAN ANTONIO, TX 78232 SERVICE(S) PROVIDED BY PROGRAM PROVIDER EMPLOYEES ONLY* : DH SE RE CS CFPH CONSUMERS ENROLLED IN THE FOLLOWING COUNTIES: NONE CONSUMERS ENROLLED STATEWIDE 0 ------------------------------------------------------------------------------ PROVIDER: 8NH ANGEL COMMUNITY SERVICES, LLC CONTRACT NUMBER : 001029055 ANGEL COMMUNITY SERVICES LLC APPLICANT CONTACT: SHERREY NAIL PHONE: (940) 456-4288 FAX: (940) 549-5263 PHYSICAL ADDRESS : 2929 HYW. 16, GRAHAM, TX 76450 SERVICE(S) PROVIDED BY PROGRAM PROVIDER EMPLOYEES ONLY* : DH SE RE CS CFPH CONSUMERS ENROLLED IN THE FOLLOWING COUNTIES: NONE CONSUMERS ENROLLED STATEWIDE 0 ------------------------------------------------------------------------------ PROVIDER: 8UZ ANTHONIA UCHE NWADINOBI * DH-DAY HAB, SE-SUPORRTED EMP, RE-RESPITE, CS-COMMUNITY SUPPORT DATE PREPARED: 01-09-21 H H S C REPORT NO.: HC062097 TIME PREPARED: 06:47 TXHML PROGRAM PROVIDER INFORMATION PAGE : 16 WAIVER CONTRACT AREA: 6 MRA: 030 AUSTIN TRAVIS INTEGRAL CARE CONTRACT NUMBER : 001024059 PARADISE CARE CENTER APPLICANT CONTACT: ANTHONIA NWADINOBI PHONE: (281) 250-1067 FAX: (713) 497-5375 PHYSICAL ADDRESS : 5326 WEST BELFORT 102, HOUSTON, TX 77035 SERVICE(S) PROVIDED BY PROGRAM PROVIDER EMPLOYEES ONLY* : DH SE RE CS CFPH CONSUMERS ENROLLED IN THE FOLLOWING COUNTIES: NONE CONSUMERS ENROLLED STATEWIDE 56 ------------------------------------------------------------------------------ PROVIDER: 8ZG ASSURED QUALITY CARE SERVICES CONTRACT NUMBER : 001031292 ASSURED QUALITY CARE SERVICES LLC APPLICANT CONTACT: STACY WILLIAMS JACKSON PHONE: (936) 414-0988 FAX: (281) 272-1467 PHYSICAL ADDRESS : 7544 FM 1960 EAST 352, HUMBLE, TX 77346 SERVICE(S) PROVIDED BY PROGRAM PROVIDER EMPLOYEES ONLY* : DH SE RE CS CFPH CONSUMERS ENROLLED IN THE FOLLOWING COUNTIES: BELL 1 CONSUMERS ENROLLED STATEWIDE 72 ------------------------------------------------------------------------------ PROVIDER: 030 AUSTIN-TRAVIS COUNTY MHMR CENTER CONTRACT NUMBER : 001010363 AUSTIN-TRAVIS COUNTY MHMR CENTER APPLICANT CONTACT: VIRGINIA SIFUENTES PHONE: (512) 483-5883 FAX: (512) 483-5827 PHYSICAL ADDRESS : 5225 NORTH LAMAR BLVD,, AUSTIN, TX 78751 SERVICE(S) PROVIDED BY PROGRAM PROVIDER EMPLOYEES ONLY* : CS CFPH CONSUMERS ENROLLED IN THE FOLLOWING COUNTIES: TRAVIS 35 CONSUMERS ENROLLED STATEWIDE 35 ------------------------------------------------------------------------------ PROVIDER: 8SU BECK AND JOHNSON COMMUNITY SERVICES CONTRACT NUMBER : 001024188 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 SERVICE(S) PROVIDED BY PROGRAM PROVIDER EMPLOYEES ONLY* : DH SE RE CS CFPH CONSUMERS ENROLLED IN THE FOLLOWING COUNTIES: NONE CONSUMERS ENROLLED STATEWIDE 4 ------------------------------------------------------------------------------ PROVIDER: 88G BERRY FAMILY SERVICES, INC. CONTRACT NUMBER : 001030343 BERRY FAMILY SERVICES INC APPLICANT CONTACT: CINDY BERRY PHONE: (972) 412-4707 FAX: (972) 202-0314 PHYSICAL ADDRESS : 5700 ROWLETT RD STE 110, ROWLETT, TX 75089-7919 SERVICE(S) PROVIDED BY PROGRAM PROVIDER EMPLOYEES ONLY* : DH SE RE CS CFPH CONSUMERS ENROLLED IN THE FOLLOWING COUNTIES: BELL 1 BRAZOS 2 MILAM 4 CONSUMERS ENROLLED STATEWIDE 1049 ------------------------------------------------------------------------------ PROVIDER: 7CM BLEU ARC INC CONTRACT NUMBER : 001031138 BLEU ARC INC APPLICANT CONTACT: ADAORA EMMANUEL PHONE: (832) 443-9734 FAX: (888) 712-8479 PHYSICAL ADDRESS : 3427 NORWICH GARDENS LANE, FULSHEAR, TX 77441 SERVICE(S) PROVIDED BY PROGRAM PROVIDER EMPLOYEES ONLY* : DH SE RE CS CFPH CONSUMERS ENROLLED IN THE FOLLOWING COUNTIES: NONE CONSUMERS ENROLLED STATEWIDE 5 * DH-DAY HAB, SE-SUPORRTED EMP, RE-RESPITE, CS-COMMUNITY SUPPORT DATE PREPARED: 01-09-21 H H S C REPORT NO.: HC062097 TIME PREPARED: 06:47 TXHML PROGRAM PROVIDER INFORMATION PAGE : 17 WAIVER CONTRACT AREA: 6 MRA: 030 AUSTIN TRAVIS INTEGRAL CARE ------------------------------------------------------------------------------ PROVIDER: 7FE C AND J HEALTHCARE SERVICES LL CONTRACT NUMBER : 001029581 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 SERVICE(S) PROVIDED BY PROGRAM PROVIDER EMPLOYEES ONLY* : DH SE RE CS CFPH CONSUMERS ENROLLED IN THE FOLLOWING COUNTIES: NONE CONSUMERS ENROLLED STATEWIDE 1 ------------------------------------------------------------------------------ PROVIDER: 7DJ CHARLOTTE BOSTON SCOTT CONTRACT NUMBER : 001024152 JOYFUL DAYS APPLICANT CONTACT: CHARLOTTE SCOTT PHONE: (800) 420-5539 FAX: (318) 505-5160 PHYSICAL ADDRESS : 508 GLENWICK DR, DESOTO, TX 75115 SERVICE(S) PROVIDED BY PROGRAM PROVIDER EMPLOYEES ONLY* : DH SE RE CS CFPH CONSUMERS ENROLLED IN THE FOLLOWING COUNTIES: NONE CONSUMERS ENROLLED STATEWIDE 0 ------------------------------------------------------------------------------ PROVIDER: 8WP CHERYL KYLE CHRISTIAN CONTRACT NUMBER : 001029829 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 SERVICE(S) PROVIDED BY PROGRAM PROVIDER EMPLOYEES ONLY* : DH SE RE CS CFPH CONSUMERS ENROLLED IN THE FOLLOWING COUNTIES: NONE CONSUMERS ENROLLED STATEWIDE 44 ------------------------------------------------------------------------------ PROVIDER: 87L CHRISBORN INC CONTRACT NUMBER : 001010385 CHRISBORN INC APPLICANT CONTACT: OSI NWADIEI PHONE: (713) 725-4730 FAX: (281) 498-0013 PHYSICAL ADDRESS : 10623 UMBER CT, HOUSTON, TX 77099 SERVICE(S) PROVIDED BY PROGRAM PROVIDER EMPLOYEES ONLY* : SE RE CS CFPH CONSUMERS ENROLLED IN THE FOLLOWING COUNTIES: NONE CONSUMERS ENROLLED STATEWIDE 24 ------------------------------------------------------------------------------ PROVIDER: 86D CLETUS O OKONKWO CONTRACT NUMBER : 001010493 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 SERVICE(S) PROVIDED BY PROGRAM PROVIDER EMPLOYEES ONLY* : DH SE RE CS CFPH CONSUMERS ENROLLED IN THE FOLLOWING COUNTIES: NONE CONSUMERS ENROLLED STATEWIDE 2 ------------------------------------------------------------------------------ PROVIDER: 792 COACE HEALTH CARE SERVICES INC CONTRACT NUMBER : 001011914 COACE HEALTH CARE SERVICES INC APPLICANT CONTACT: ANYAGAFU EDITH PHONE: (832) 704-2338 FAX: (713) 484-8824 PHYSICAL ADDRESS : 10039 BISSONNET ST #227, HOUSTON, TX 77036 * DH-DAY HAB, SE-SUPORRTED EMP, RE-RESPITE, CS-COMMUNITY SUPPORT DATE PREPARED: 01-09-21 H H S C REPORT NO.: HC062097 TIME PREPARED: 06:47 TXHML PROGRAM PROVIDER INFORMATION PAGE : 18 WAIVER CONTRACT AREA: 6 MRA: 030 AUSTIN TRAVIS INTEGRAL CARE SERVICE(S) PROVIDED BY PROGRAM PROVIDER EMPLOYEES ONLY* : DH SE RE CS CFPH CONSUMERS ENROLLED IN THE FOLLOWING COUNTIES: NONE CONSUMERS ENROLLED STATEWIDE 0 ------------------------------------------------------------------------------ PROVIDER: 830 COMMUNITY OPTIONS, INC. CONTRACT NUMBER : 001010379 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 SERVICE(S) PROVIDED BY PROGRAM PROVIDER EMPLOYEES ONLY* : SE CS CFPH CONSUMERS ENROLLED IN THE FOLLOWING COUNTIES: WILLIAMSON 3 CONSUMERS ENROLLED STATEWIDE 473 ------------------------------------------------------------------------------ PROVIDER: 7D5 CORINTHIA LILLIE ALFORD CONTRACT NUMBER : 001024131 RUTHERFORD ENTERPRISE APPLICANT CONTACT: CORINTHIA L ALFORD PHONE: (972) 325-6527 FAX: (888) 251-5036 PHYSICAL ADDRESS : 4013 EASTON MEADOWSN DR #101, GARLAND, TX 75043 SERVICE(S) PROVIDED BY PROGRAM PROVIDER EMPLOYEES ONLY* : DH SE RE CS CFPH CONSUMERS ENROLLED IN THE FOLLOWING COUNTIES: NONE CONSUMERS ENROLLED STATEWIDE 0 ------------------------------------------------------------------------------ PROVIDER: 891 D & S RESIDENTIAL SERVICES, LP CONTRACT NUMBER : 001010380 THLWCA06 APPLICANT CONTACT: BROOKE HASTY PHONE: (512) 328-8484 FAX: (512) 327-1372 PHYSICAL ADDRESS : 209 E BEN WHITE BLVD SUITE 204, AUSTIN, TX 78704 SERVICE(S) PROVIDED BY PROGRAM PROVIDER EMPLOYEES ONLY* : DH RE CONSUMERS ENROLLED IN THE FOLLOWING COUNTIES: BASTROP 6 BELL 2 BRAZOS 15 BURNET 8 CALDWELL 7 CORYELL 1 FAYETTE 1 GRIMES 3 GUADALUPE 4 LAMPASAS 1 LEE 9 LEON 4 MADISON 1 ROBERTSON 1 TRAVIS 5 WASHINGTON 2 WILLIAMSON 9 CONSUMERS ENROLLED STATEWIDE 2277 ------------------------------------------------------------------------------ PROVIDER: 7G5 DDWD DEVELOPMENTAL HCS SERVICES INC CONTRACT NUMBER : 001030146 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 SERVICE(S) PROVIDED BY PROGRAM PROVIDER EMPLOYEES ONLY* : DH SE RE CS CFPH CONSUMERS ENROLLED IN THE FOLLOWING COUNTIES: NONE CONSUMERS ENROLLED STATEWIDE 20 ------------------------------------------------------------------------------ PROVIDER: 8DW DRACO SERVICES, INC. CONTRACT NUMBER : 001010386 DRACO SERVICES, INC. APPLICANT CONTACT: GORDON ISRAEL PHONE: (512) 426-3655 FAX: (512) 440-8800 PHYSICAL ADDRESS : 4025 MANCHACA RD, AUSTIN, TX 78704 SERVICE(S) PROVIDED BY PROGRAM PROVIDER EMPLOYEES ONLY* : CS CFPH CONSUMERS ENROLLED IN THE FOLLOWING COUNTIES: GONZALES 1 TRAVIS 5 WILLIAMSON 2 CONSUMERS ENROLLED STATEWIDE 259 * DH-DAY HAB, SE-SUPORRTED EMP, RE-RESPITE, CS-COMMUNITY SUPPORT DATE PREPARED: 01-09-21 H H S C REPORT NO.: HC062097 TIME PREPARED: 06:47 TXHML PROGRAM PROVIDER INFORMATION PAGE : 19 WAIVER CONTRACT AREA: 6 MRA: 030 AUSTIN TRAVIS INTEGRAL CARE ------------------------------------------------------------------------------ PROVIDER: 804 EDUCARE COMMUNITY LIVING CORPORATION - TEXAS CONTRACT NUMBER : 001010388 EDUCARE COMMUNITY LIVING CORPORATIO APPLICANT CONTACT: ANNETTE SMITH PHONE: (512) 454-3795 FAX: (512) 302-3978 PHYSICAL ADDRESS : 1033 LA POSADA SUITE 210, AUSTON, TX 78752 SERVICE(S) PROVIDED BY PROGRAM PROVIDER EMPLOYEES ONLY* : SE CONSUMERS ENROLLED IN THE FOLLOWING COUNTIES: NONE CONSUMERS ENROLLED STATEWIDE 1139 ------------------------------------------------------------------------------ PROVIDER: 831 EDUCARE COMMUNITY LIVING-NORMAL LIFE INC CONTRACT NUMBER : 001010389 EDUCARE COMMUNITY LIVING-NORMAL LIF APPLICANT CONTACT: DEBBIE ADRIAN PHONE: (254) 773-8453 FAX: (254) 773-2629 PHYSICAL ADDRESS : 2828 COTTONWOOD LANE, TEMPLE, TX 76502 SERVICE(S) PROVIDED BY PROGRAM PROVIDER EMPLOYEES ONLY* : SE RE CONSUMERS ENROLLED IN THE FOLLOWING COUNTIES: BELL 26 CORYELL 2 CONSUMERS ENROLLED STATEWIDE 228 ------------------------------------------------------------------------------ PROVIDER: 85M EXCEPTIONAL EMPLOYMENT SERVICES, INC. CONTRACT NUMBER : 001010392 EXCEPTIONAL EMPLOYMENT SERVICES APPLICANT CONTACT: KIMBERLY STEVENSON PHONE: (512) 970-9313 FAX: (512) 926-5773 PHYSICAL ADDRESS : RIDGEPOINT DRIVE #130, AUSTIN, TX 78754 SERVICE(S) PROVIDED BY PROGRAM PROVIDER EMPLOYEES ONLY* : SE CONSUMERS ENROLLED IN THE FOLLOWING COUNTIES: TRAVIS 1 CONSUMERS ENROLLED STATEWIDE 74 ------------------------------------------------------------------------------ PROVIDER: 8XD FOREVER FAMILIES INC CONTRACT NUMBER : 001011579 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 SERVICE(S) PROVIDED BY PROGRAM PROVIDER EMPLOYEES ONLY* : DH SE RE CS CFPH CONSUMERS ENROLLED IN THE FOLLOWING COUNTIES: NONE CONSUMERS ENROLLED STATEWIDE 17 ------------------------------------------------------------------------------ PROVIDER: 82I HILL COUNTRY SAN ANTONIO MANAGEMENT INC CONTRACT NUMBER : 001011355 HILL COUNTRY SAN ANTONIO MANAGEMENT APPLICANT CONTACT: CHERYL STANDIFER PHONE: (210) 340-8256 FAX: (210) 340-8302 PHYSICAL ADDRESS : 358 FM 1626, AUSTIN, TX 78748 SERVICE(S) PROVIDED BY PROGRAM PROVIDER EMPLOYEES ONLY* : DH RE CONSUMERS ENROLLED IN THE FOLLOWING COUNTIES: NONE CONSUMERS ENROLLED STATEWIDE 164 ------------------------------------------------------------------------------ PROVIDER: 7D4 IMAGINE ART, INCORPORATED CONTRACT NUMBER : 001029095 IMAGINE ART APPLICANT CONTACT: DEBORAH KIZER PHONE: (512) 554-2406 FAX: (512) 524-4948 PHYSICAL ADDRESS : 2830 REAL STREET, AUSTIN, TX 78722 * DH-DAY HAB, SE-SUPORRTED EMP, RE-RESPITE, CS-COMMUNITY SUPPORT DATE PREPARED: 01-09-21 H H S C REPORT NO.: HC062097 TIME PREPARED: 06:47 TXHML PROGRAM PROVIDER INFORMATION PAGE : 20 WAIVER CONTRACT AREA: 6 MRA: 030 AUSTIN TRAVIS INTEGRAL CARE SERVICE(S) PROVIDED BY PROGRAM PROVIDER EMPLOYEES ONLY* : DH SE RE CS CFPH CONSUMERS ENROLLED IN THE FOLLOWING COUNTIES: TRAVIS 4 CONSUMERS ENROLLED STATEWIDE 32 ------------------------------------------------------------------------------ PROVIDER: 7EQ INNOVATIVE STEPS CO CONTRACT NUMBER : 001029192 INNOVATIVE STEPS CO APPLICANT CONTACT: BRANDON DAVIS PHONE: (972) 821-9503 FAX: (940) 440-1301 PHYSICAL ADDRESS : 1509 COCATIEL DRIVE, LITTLE ELM, TX 75068 SERVICE(S) PROVIDED BY PROGRAM PROVIDER EMPLOYEES ONLY* : DH SE RE CS CFPH CONSUMERS ENROLLED IN THE FOLLOWING COUNTIES: NONE CONSUMERS ENROLLED STATEWIDE 46 ------------------------------------------------------------------------------ PROVIDER: 8QN ISSAC D EARLS CONTRACT NUMBER : 001010769 CONNECTING LIVES SERVICES APPLICANT CONTACT: ISSAC EARLS PHONE: (512) 386-6600 FAX: (512) 386-8180 PHYSICAL ADDRESS : 7901 CAMERON RD. BLDG. 2 STE. 219, AUSTIN, TX 78754 SERVICE(S) PROVIDED BY PROGRAM PROVIDER EMPLOYEES ONLY* : SE CONSUMERS ENROLLED IN THE FOLLOWING COUNTIES: LAMPASAS 1 ROBERTSON 1 CONSUMERS ENROLLED STATEWIDE 33 ------------------------------------------------------------------------------ PROVIDER: 88V IVY REIGN SUPPORT SERVICES CONTRACT NUMBER : 001011277 IVY REIGN SUPPORT SERVICES APPLICANT CONTACT: TERRENCE TOLIVER PHONE: (254) 799-3900 FAX: (254) 799-3902 PHYSICAL ADDRESS : 2029 WASHINGTON AVE, WACO, TX 76701 SERVICE(S) PROVIDED BY PROGRAM PROVIDER EMPLOYEES ONLY* : DH SE RE CS CFPH CONSUMERS ENROLLED IN THE FOLLOWING COUNTIES: BELL 1 MCLENNAN 2 CONSUMERS ENROLLED STATEWIDE 72 ------------------------------------------------------------------------------ PROVIDER: 7GB KEMA CARE SERVICES INC CONTRACT NUMBER : 001030622 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 SERVICE(S) PROVIDED BY PROGRAM PROVIDER EMPLOYEES ONLY* : DH SE RE CS CFPH CONSUMERS ENROLLED IN THE FOLLOWING COUNTIES: NONE CONSUMERS ENROLLED STATEWIDE 8 ------------------------------------------------------------------------------ PROVIDER: 7EG LASHABRIA R EVANS CONTRACT NUMBER : 001028946 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 SERVICE(S) PROVIDED BY PROGRAM PROVIDER EMPLOYEES ONLY* : DH SE RE CS CFPH CONSUMERS ENROLLED IN THE FOLLOWING COUNTIES: NONE CONSUMERS ENROLLED STATEWIDE 25 ------------------------------------------------------------------------------ PROVIDER: 8CR MARY LEE FOUNDATION * DH-DAY HAB, SE-SUPORRTED EMP, RE-RESPITE, CS-COMMUNITY SUPPORT DATE PREPARED: 01-09-21 H H S C REPORT NO.: HC062097 TIME PREPARED: 06:47 TXHML PROGRAM PROVIDER INFORMATION PAGE : 21 WAIVER CONTRACT AREA: 6 MRA: 030 AUSTIN TRAVIS INTEGRAL CARE CONTRACT NUMBER : 001010206 MARY LEE FOUNDATION-SOUTHPOINTE APPLICANT CONTACT: JOHN MCPHAIL PHONE: (512) 442-6077 FAX: (512) 442-6825 PHYSICAL ADDRESS : 1334 LAMAR SQUARE DRIVE, AUSTIN, TX 78704 SERVICE(S) PROVIDED BY PROGRAM PROVIDER EMPLOYEES ONLY* : DH SE RE CS CFPH CONSUMERS ENROLLED IN THE FOLLOWING COUNTIES: TRAVIS 22 CONSUMERS ENROLLED STATEWIDE 94 ------------------------------------------------------------------------------ PROVIDER: 7BH NAYOBI HEALTH SERVICES LLC CONTRACT NUMBER : 001023914 NAYOBI HEALTH SERVICES,LLC APPLICANT CONTACT: KEKEOCHA CATHERINE PHONE: (832) 326-2010 FAX: (888) 566-4246 PHYSICAL ADDRESS : 5038 LAKESHORE DRIVE, WILLIS, TX 77318 SERVICE(S) PROVIDED BY PROGRAM PROVIDER EMPLOYEES ONLY* : DH SE RE CS CFPH CONSUMERS ENROLLED IN THE FOLLOWING COUNTIES: NONE CONSUMERS ENROLLED STATEWIDE 0 ------------------------------------------------------------------------------ PROVIDER: 7BC NICOLE LASHAWN MAYS CONTRACT NUMBER : 001029876 NICOLE LASHAWN MAYS APPLICANT CONTACT: NICOLE MAYS PHONE: (713) 594-0469 FAX: (713) 583-0900 PHYSICAL ADDRESS : 18318 ENCHANTED ROCK TRAIL, HUMBLE, TX 77346 SERVICE(S) PROVIDED BY PROGRAM PROVIDER EMPLOYEES ONLY* : DH SE RE CS CFPH CONSUMERS ENROLLED IN THE FOLLOWING COUNTIES: NONE CONSUMERS ENROLLED STATEWIDE 26 ------------------------------------------------------------------------------ PROVIDER: 8YC NKEIRU PRISCA UCHEM CONTRACT NUMBER : 001024198 GRACEFUL CARE CENTER APPLICANT CONTACT: NKEIRU PRISCA, UCHE PHONE: (832) 607-5664 FAX: (281) 498-9935 PHYSICAL ADDRESS : 14922 HAVENRIDGE DR., HOUSTON, TX 77083 SERVICE(S) PROVIDED BY PROGRAM PROVIDER EMPLOYEES ONLY* : DH SE RE CS CFPH CONSUMERS ENROLLED IN THE FOLLOWING COUNTIES: NONE CONSUMERS ENROLLED STATEWIDE 2 ------------------------------------------------------------------------------ PROVIDER: 7D1 N2 CARE SERVICES INC CONTRACT NUMBER : 001024094 N2 CARE SERVICES INC APPLICANT CONTACT: IKE ALARIBE PHONE: (832) 859-8777 FAX: (281) 639-6364 PHYSICAL ADDRESS : 5827 CRESTVIEW COVE, RICHMOND, TX 77469 SERVICE(S) PROVIDED BY PROGRAM PROVIDER EMPLOYEES ONLY* : DH SE RE CS CFPH CONSUMERS ENROLLED IN THE FOLLOWING COUNTIES: NONE CONSUMERS ENROLLED STATEWIDE 8 ------------------------------------------------------------------------------ PROVIDER: 8C1 PAULINE IGWE CONTRACT NUMBER : 001010419 HUMAN SERVICES CENTER APPLICANT CONTACT: PAULINE IGWE PHONE: (713) 778-1616 FAX: (713) 778-1726 PHYSICAL ADDRESS : 10101 FONDREN RD. #532, HOUSTON, TX 77096 SERVICE(S) PROVIDED BY PROGRAM PROVIDER EMPLOYEES ONLY* : DH SE RE CS CFPH CONSUMERS ENROLLED IN THE FOLLOWING COUNTIES: NONE CONSUMERS ENROLLED STATEWIDE 134 * DH-DAY HAB, SE-SUPORRTED EMP, RE-RESPITE, CS-COMMUNITY SUPPORT DATE PREPARED: 01-09-21 H H S C REPORT NO.: HC062097 TIME PREPARED: 06:47 TXHML PROGRAM PROVIDER INFORMATION PAGE : 22 WAIVER CONTRACT AREA: 6 MRA: 030 AUSTIN TRAVIS INTEGRAL CARE ------------------------------------------------------------------------------ PROVIDER: 808 PREMIEANT INCORPORATED CONTRACT NUMBER : 001010422 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 SERVICE(S) PROVIDED BY PROGRAM PROVIDER EMPLOYEES ONLY* : CS CFPH CONSUMERS ENROLLED IN THE FOLLOWING COUNTIES: NONE CONSUMERS ENROLLED STATEWIDE 278 ------------------------------------------------------------------------------ PROVIDER: 7DB SHAREL SULLIVAN CONTRACT NUMBER : 001024179 THE HARMONY PLACE HOME APPLICANT CONTACT: SULLIVAN SHAREL PHONE: (972) 670-0559 FAX: (972) 287-4204 PHYSICAL ADDRESS : 2115 TRADEWIND DR, MESQUITE, TX 75150 SERVICE(S) PROVIDED BY PROGRAM PROVIDER EMPLOYEES ONLY* : DH SE RE CS CFPH CONSUMERS ENROLLED IN THE FOLLOWING COUNTIES: NONE CONSUMERS ENROLLED STATEWIDE 41 ------------------------------------------------------------------------------ PROVIDER: 7EU TOTAL FRIENDLY CARE SERVICES I CONTRACT NUMBER : 001029431 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 SERVICE(S) PROVIDED BY PROGRAM PROVIDER EMPLOYEES ONLY* : DH SE RE CS CFPH CONSUMERS ENROLLED IN THE FOLLOWING COUNTIES: NONE CONSUMERS ENROLLED STATEWIDE 22 ------------------------------------------------------------------------------ PROVIDER: 8WT UNIQUE MANOR AND REHAB LLC CONTRACT NUMBER : 001011089 UNIQUE MANOR AND REHAB LLC APPLICANT CONTACT: BERNADETTE KEKE PHONE: (832) 260-3763 FAX: (713) 988-0000 PHYSICAL ADDRESS : 10101 SW FREEWAY,STE 110, HOUSTON, TX 77074 SERVICE(S) PROVIDED BY PROGRAM PROVIDER EMPLOYEES ONLY* : DH SE RE CS CFPH CONSUMERS ENROLLED IN THE FOLLOWING COUNTIES: NONE CONSUMERS ENROLLED STATEWIDE 13 ------------------------------------------------------------------------------ PROVIDER: 84S VICTORIA EBIOGWU ANAGHARA CONTRACT NUMBER : 001024167 ADONAI'S HEALTHCARE CENTER APPLICANT CONTACT: VICTORIA E. ANAGHARA PHONE: (832) 289-8085 FAX: (713) 271-7400 PHYSICAL ADDRESS : 17015 COSTERO DR, HOUSTON, TX 77083 SERVICE(S) PROVIDED BY PROGRAM PROVIDER EMPLOYEES ONLY* : DH SE RE CS CFPH CONSUMERS ENROLLED IN THE FOLLOWING COUNTIES: NONE CONSUMERS ENROLLED STATEWIDE 1 ------------------------------------------------------------------------------ PROVIDER: 83C VIRGINIA R THURMAN CONTRACT NUMBER : 001010439 CLYDIES PLACE APPLICANT CONTACT: VIRGINIA R. THURMAN PHONE: (903) 855-0845 FAX: (903) 855-0899 PHYSICAL ADDRESS : 424 HENDERSON STREET, PITTSBURG, TX 75686 * DH-DAY HAB, SE-SUPORRTED EMP, RE-RESPITE, CS-COMMUNITY SUPPORT DATE PREPARED: 01-09-21 H H S C REPORT NO.: HC062097 TIME PREPARED: 06:47 TXHML PROGRAM PROVIDER INFORMATION PAGE : 23 WAIVER CONTRACT AREA: 6 MRA: 030 AUSTIN TRAVIS INTEGRAL CARE SERVICE(S) PROVIDED BY PROGRAM PROVIDER EMPLOYEES ONLY* : SE CONSUMERS ENROLLED IN THE FOLLOWING COUNTIES: BELL 1 CONSUMERS ENROLLED STATEWIDE 19 ------------------------------------------------------------------------------ PROVIDER: 7DR 1 CARE PREMIER SERVICES LLC CONTRACT NUMBER : 001029890 1 CARE PREMIER SERVICES LLC APPLICANT CONTACT: MAYS NICOLE PHONE: (713) 594-0469 FAX: (713) 583-0900 PHYSICAL ADDRESS : 18318 ENCHANTED ROCK TRAIL, HUMBLE, TX 77346 SERVICE(S) PROVIDED BY PROGRAM PROVIDER EMPLOYEES ONLY* : DH SE RE CS CFPH CONSUMERS ENROLLED IN THE FOLLOWING COUNTIES: NONE CONSUMERS ENROLLED STATEWIDE 22 TOTAL NUMBER OF CONTRACTS THIS MRA: 52 * DH-DAY HAB, SE-SUPORRTED EMP, RE-RESPITE, CS-COMMUNITY SUPPORT