Provider Demographics
NPI:1245400589
Name:PROFESSIONAL COUNSELING CENTER PLLC
Entity Type:Organization
Organization Name:PROFESSIONAL COUNSELING CENTER PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:YVETTE
Authorized Official - Middle Name:
Authorized Official - Last Name:PHILLIPS
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD
Authorized Official - Phone:817-306-9770
Mailing Address - Street 1:6612 N RIVERSIDE DR
Mailing Address - Street 2:SUITE 140
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76137-6663
Mailing Address - Country:US
Mailing Address - Phone:817-306-9770
Mailing Address - Fax:817-306-0664
Practice Address - Street 1:6612 N RIVERSIDE DR
Practice Address - Street 2:SUITE 140
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76137-6663
Practice Address - Country:US
Practice Address - Phone:817-306-9770
Practice Address - Fax:817-306-0664
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-03
Last Update Date:2008-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX63253101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1883613-01Medicaid