Basic Information
| Provider Information | |||||||||
| NPI: | 1467699652 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ANDREA HARBAUGH LPC PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3840 HULEN ST | ||||||||
| Address2: | SUITE 602 | ||||||||
| City: | FORT WORTH | ||||||||
| State: | TX | ||||||||
| PostalCode: | 761077277 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8177354165 | ||||||||
| FaxNumber: | 8177354688 | ||||||||
| Practice Location | |||||||||
| Address1: | 3840 HULEN ST | ||||||||
| Address2: | SUITE 602 | ||||||||
| City: | FORT WORTH | ||||||||
| State: | TX | ||||||||
| PostalCode: | 761077277 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8177354165 | ||||||||
| FaxNumber: | 8177354688 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/09/2009 | ||||||||
| LastUpdateDate: | 01/09/2009 | ||||||||
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| AuthorizedOfficialLastName: | HARBAUGH | ||||||||
| AuthorizedOfficialFirstName: | ANDREA | ||||||||
| AuthorizedOfficialMiddleName: | D | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 8177354165 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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| AuthorizedOfficialCredential: | MA LPC | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YP2500X | 15280 | TX | Y | 193400000X SINGLE SPECIALTY GROUP | Behavioral Health & Social Service Providers | Counselor | Professional |
ID Information
| ID | Type | State | Issuer | Description | 146244201 | 05 | TX | MEDICAID |