Provider Demographics
NPI:1417295445
Name:FORT WORTH BRIEF THERAPY CENTER, PLLC
Entity Type:Organization
Organization Name:FORT WORTH BRIEF THERAPY CENTER, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CO-OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:MATHEW
Authorized Official - Middle Name:A
Authorized Official - Last Name:TRAMMELL
Authorized Official - Suffix:
Authorized Official - Credentials:LPC-S
Authorized Official - Phone:817-301-6322
Mailing Address - Street 1:800 US HIGHWAY 287
Mailing Address - Street 2:SUITE 1
Mailing Address - City:RHOME
Mailing Address - State:TX
Mailing Address - Zip Code:76078-4323
Mailing Address - Country:US
Mailing Address - Phone:817-301-6322
Mailing Address - Fax:817-923-1490
Practice Address - Street 1:3113 S UNIVERSITY DR
Practice Address - Street 2:STE 201
Practice Address - City:FT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76109-5616
Practice Address - Country:US
Practice Address - Phone:817-923-1444
Practice Address - Fax:817-923-1490
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-01-25
Last Update Date:2013-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX62762101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX219912701Medicaid