Provider Demographics
NPI:1659541092
Name:GORTNEY, MICHELE D (LPCS)
Entity Type:Individual
Prefix:
First Name:MICHELE
Middle Name:D
Last Name:GORTNEY
Suffix:
Gender:F
Credentials:LPCS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2603
Mailing Address - Street 2:HTN, CLIENT ACCOUNTING
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76113-2603
Mailing Address - Country:US
Mailing Address - Phone:817-569-4396
Mailing Address - Fax:817-569-4517
Practice Address - Street 1:240 E RENFRO ST STE 201
Practice Address - Street 2:
Practice Address - City:BURLESON
Practice Address - State:TX
Practice Address - Zip Code:76028-3940
Practice Address - Country:US
Practice Address - Phone:817-913-1517
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-02-29
Last Update Date:2019-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX19940101YM0800X, 101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX88602LOtherBLUECROSSBLUESHIELD PROV#
TX193966201Medicaid