Basic Information
| Provider Information | |||||||||
| NPI: | 1225193204 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PARTIN | ||||||||
| FirstName: | LARRY | ||||||||
| MiddleName: | GLEN | ||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | LPC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5713 GUADALAJARA DR | ||||||||
| Address2: | |||||||||
| City: | NORTH RICHLAND HILLS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 761806123 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4698319261 | ||||||||
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| Practice Location | |||||||||
| Address1: | 320 WESTWAY PL | ||||||||
| Address2: | STE 320 | ||||||||
| City: | ARLINGTON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 760185245 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8165169100 | ||||||||
| FaxNumber: | 8175169102 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/27/2006 | ||||||||
| LastUpdateDate: | 06/24/2015 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YP2500X | 19117 | TX | Y | Behavioral Health & Social Service Providers | Counselor | Professional |
ID Information
| ID | Type | State | Issuer | Description | 182575401 | 05 | TX | MEDICAID |