Basic Information
| Provider Information | |||||||||
| NPI: | 1366813453 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | HEATH | ||||||||
| FirstName: | COREY | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 99213 | ||||||||
| Address2: | |||||||||
| City: | FORT WORTH | ||||||||
| State: | TX | ||||||||
| PostalCode: | 761990213 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6828854870 | ||||||||
| FaxNumber: | 6828853936 | ||||||||
| Practice Location | |||||||||
| Address1: | 901 7TH AVE | ||||||||
| Address2: | STE 2100 | ||||||||
| City: | FORT WORTH | ||||||||
| State: | TX | ||||||||
| PostalCode: | 761042722 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6828851480 | ||||||||
| FaxNumber: | 6828853600 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/14/2015 | ||||||||
| LastUpdateDate: | 04/09/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103T00000X | 37054 | TX | Y | Behavioral Health & Social Service Providers | Psychologist |
No ID Information.