Provider Demographics
NPI:1518392075
Name:BEAN, CAROL HOLIDAY
Entity Type:Individual
Prefix:
First Name:CAROL
Middle Name:HOLIDAY
Last Name:BEAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:C.
Other - Middle Name:HOLIDAY
Other - Last Name:BEAN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PSYD
Mailing Address - Street 1:7801 OAKMONT BLVD STE 101
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76132-4242
Mailing Address - Country:US
Mailing Address - Phone:682-841-1475
Mailing Address - Fax:682-708-3775
Practice Address - Street 1:7801 OAKMONT BLVD STE 101
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76132-4242
Practice Address - Country:US
Practice Address - Phone:682-841-1475
Practice Address - Fax:682-708-3775
Is Sole Proprietor?:Yes
Enumeration Date:2013-09-03
Last Update Date:2023-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX37244103T00000X, 103TC0700X, 103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX3675902-01Medicaid