Provider Demographics
NPI:1649777871
Name:BELLA LIVING PSYCHOLOGICAL SERVICES, PLLC
Entity Type:Organization
Organization Name:BELLA LIVING PSYCHOLOGICAL SERVICES, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:RENEE
Authorized Official - Middle Name:
Authorized Official - Last Name:LEXOW
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD
Authorized Official - Phone:616-485-2116
Mailing Address - Street 1:9609 LAKEWAY CIR APT 7108
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76179-6205
Mailing Address - Country:US
Mailing Address - Phone:616-485-2116
Mailing Address - Fax:
Practice Address - Street 1:4500 MERCANTILE PLAZA DR STE 300
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76137-4206
Practice Address - Country:US
Practice Address - Phone:817-361-4317
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-04-13
Last Update Date:2018-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX37675261QM0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)