Basic Information
| Provider Information | |||||||||
| NPI: | 1992385033 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | CROSSROADS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6733 CAMP BOWIE BLVD | ||||||||
| Address2: | |||||||||
| City: | FORT WORTH | ||||||||
| State: | TX | ||||||||
| PostalCode: | 761167112 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8173869180 | ||||||||
| FaxNumber: | 8173869138 | ||||||||
| Practice Location | |||||||||
| Address1: | 6733 CAMP BOWIE BLVD | ||||||||
| Address2: | |||||||||
| City: | FORT WORTH | ||||||||
| State: | TX | ||||||||
| PostalCode: | 761167112 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8173869180 | ||||||||
| FaxNumber: | 8173869138 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/13/2021 | ||||||||
| LastUpdateDate: | 04/13/2021 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | ARNOLD-BULLS | ||||||||
| AuthorizedOfficialFirstName: | TAMMY | ||||||||
| AuthorizedOfficialMiddleName: | S | ||||||||
| AuthorizedOfficialTitleorPosition: | COUNSELOR | ||||||||
| AuthorizedOfficialTelephone: | 8173869180 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MS. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | LCDC | ||||||||
| NPICertificationDate: | 04/13/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 276400000X | Y | Hospital Units | Rehabilitation, Substance Use Disorder Unit |
No ID Information.