Provider Demographics
NPI:1215551031
Name:COTHRAN, LEAH KLYCE (LPC, LCDC)
Entity Type:Individual
Prefix:
First Name:LEAH
Middle Name:KLYCE
Last Name:COTHRAN
Suffix:
Gender:F
Credentials:LPC, LCDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 470001
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76147-0001
Mailing Address - Country:US
Mailing Address - Phone:817-991-2280
Mailing Address - Fax:
Practice Address - Street 1:4200 S HULEN ST STE 674
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76109-4987
Practice Address - Country:US
Practice Address - Phone:682-231-3834
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-06-08
Last Update Date:2020-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX14448101YA0400X
TX73729101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)