Provider Demographics
NPI:1437450780
Name:BEARDEN, MICHAEL COREY (LPC)
Entity Type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:COREY
Last Name:BEARDEN
Suffix:
Gender:M
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2209 EDWIN ST
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76110-1215
Mailing Address - Country:US
Mailing Address - Phone:817-897-7247
Mailing Address - Fax:817-549-0293
Practice Address - Street 1:1810 8TH AVE
Practice Address - Street 2:SUITE A
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76110-1352
Practice Address - Country:US
Practice Address - Phone:817-897-7247
Practice Address - Fax:817-549-0293
Is Sole Proprietor?:Yes
Enumeration Date:2010-11-03
Last Update Date:2013-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX66256101YM0800X, 101YP1600X, 106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YP1600XBehavioral Health & Social Service ProvidersCounselorPastoral
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX2951303-01Medicaid