Provider Demographics
NPI:1629045497
Name:FAHRENBRUCK, WILLEM H (LCPC)
Entity Type:Individual
Prefix:MR
First Name:WILLEM
Middle Name:H
Last Name:FAHRENBRUCK
Suffix:
Gender:M
Credentials:LCPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1513 MIAMI DR
Mailing Address - Street 2:
Mailing Address - City:LONGVIEW
Mailing Address - State:TX
Mailing Address - Zip Code:75601-3553
Mailing Address - Country:US
Mailing Address - Phone:605-440-2145
Mailing Address - Fax:
Practice Address - Street 1:3122 NEALY WAY STE 219
Practice Address - Street 2:
Practice Address - City:LONGVIEW
Practice Address - State:TX
Practice Address - Zip Code:75605-1088
Practice Address - Country:US
Practice Address - Phone:903-452-8040
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-01
Last Update Date:2023-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX83081101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT0000742270OtherBC BS PROVIDER NUMBER
MT0256724Medicaid