Basic Information
Provider Information | |||||||||
NPI: | 1437349859 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | MY HEALTH MY RESOURCES OF TARRANT COUNTY | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | LPC MEDICAID GROUP | ||||||||
OtherOrganizationType: | 5 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 2603 | ||||||||
Address2: | HTN, CLIENT ACCOUNTING | ||||||||
City: | FORT WORTH | ||||||||
State: | TX | ||||||||
PostalCode: | 761132603 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8175694395 | ||||||||
FaxNumber: | 8175694517 | ||||||||
Practice Location | |||||||||
Address1: | 3840 HULEN ST | ||||||||
Address2: | HTN, CLIENT ACCOUNTING | ||||||||
City: | FORT WORTH | ||||||||
State: | TX | ||||||||
PostalCode: | 761077277 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8175694395 | ||||||||
FaxNumber: | 8175694517 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 08/01/2007 | ||||||||
LastUpdateDate: | 08/31/2017 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | MONTES | ||||||||
AuthorizedOfficialFirstName: | YOLANDA | ||||||||
AuthorizedOfficialMiddleName: | F | ||||||||
AuthorizedOfficialTitleorPosition: | ENROLLMENT COORDINATOR | ||||||||
AuthorizedOfficialTelephone: | 8175695235 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | MS. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YP2500X |   |   | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Behavioral Health & Social Service Providers | Counselor | Professional |
ID Information
ID | Type | State | Issuer | Description | 135082908 | 05 | TX |   | MEDICAID |