Provider Demographics
NPI:1891559159
Name:WILLINGHAM, JULIE GLASS (MSAC, LCDC)
Entity Type:Individual
Prefix:
First Name:JULIE
Middle Name:GLASS
Last Name:WILLINGHAM
Suffix:
Gender:F
Credentials:MSAC, LCDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:136 ANITA AVE
Mailing Address - Street 2:
Mailing Address - City:KELLER
Mailing Address - State:TX
Mailing Address - Zip Code:76248-2435
Mailing Address - Country:US
Mailing Address - Phone:469-516-4574
Mailing Address - Fax:
Practice Address - Street 1:6115 CAMP BOWIE BLVD STE 220
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76116-5543
Practice Address - Country:US
Practice Address - Phone:888-734-2289
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-02-07
Last Update Date:2024-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX6687101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)