Provider Demographics
NPI:1689387797
Name:SOUTHLAKE CHILD AND FAMILY THERAPY
Entity Type:Organization
Organization Name:SOUTHLAKE CHILD AND FAMILY THERAPY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:KATHARINE
Authorized Official - Middle Name:ANNE
Authorized Official - Last Name:OTTONE DAVIS
Authorized Official - Suffix:
Authorized Official - Credentials:PHD, LPC
Authorized Official - Phone:817-266-8676
Mailing Address - Street 1:1933 BERKELEY PL
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76110-1209
Mailing Address - Country:US
Mailing Address - Phone:817-266-8676
Mailing Address - Fax:
Practice Address - Street 1:2141 KIRKWOOD BLVD STE 130
Practice Address - Street 2:
Practice Address - City:SOUTHLAKE
Practice Address - State:TX
Practice Address - Zip Code:76092-1464
Practice Address - Country:US
Practice Address - Phone:817-266-8676
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-01-04
Last Update Date:2023-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty