Provider Demographics
NPI:1417254319
Name:ANZUALDA, DAWN MICHELLE (LPC)
Entity Type:Individual
Prefix:
First Name:DAWN
Middle Name:MICHELLE
Last Name:ANZUALDA
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4501 STEPPING STONE DR
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76123-1871
Mailing Address - Country:US
Mailing Address - Phone:817-637-9101
Mailing Address - Fax:
Practice Address - Street 1:3901 AIRPORT FWY
Practice Address - Street 2:SUITE 230
Practice Address - City:BEDFORD
Practice Address - State:TX
Practice Address - Zip Code:76021-6117
Practice Address - Country:US
Practice Address - Phone:817-354-5200
Practice Address - Fax:817-354-5201
Is Sole Proprietor?:Yes
Enumeration Date:2011-02-12
Last Update Date:2011-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX63545101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional