Basic Information
| Provider Information | |||||||||
| NPI: | 1528459914 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MICHELE D. GORTNEY, LPC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 240 E RENFRO ST | ||||||||
| Address2: | SUITE 201 | ||||||||
| City: | BURLESON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 760283938 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8179131517 | ||||||||
| FaxNumber: | 8172957815 | ||||||||
| Practice Location | |||||||||
| Address1: | 240 E RENFRO ST | ||||||||
| Address2: | SUITE 201 | ||||||||
| City: | BURLESON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 760283938 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8179131517 | ||||||||
| FaxNumber: | 8172957815 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/06/2015 | ||||||||
| LastUpdateDate: | 02/06/2015 | ||||||||
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| AuthorizedOfficialLastName: | GORTNEY | ||||||||
| AuthorizedOfficialFirstName: | MICHELE | ||||||||
| AuthorizedOfficialMiddleName: | D | ||||||||
| AuthorizedOfficialTitleorPosition: | COUNSELOR/DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 8179131517 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MS, LPC | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | 38240 | TX | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Social Worker | Clinical | 101YP2500X | 19940 | TX | Y | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Counselor | Professional |
ID Information
| ID | Type | State | Issuer | Description | 2092363 | 05 | TX | MEDICAID | 193966202 | 05 | TX | MEDICAID |