Provider Demographics
NPI:1912555012
Name:GREENBACH, MYLIE (MS, LPC, RPT, NCC)
Entity Type:Individual
Prefix:MS
First Name:MYLIE
Middle Name:
Last Name:GREENBACH
Suffix:
Gender:F
Credentials:MS, LPC, RPT, NCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7009 BRIERHOLLOW CT
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76132-7110
Mailing Address - Country:US
Mailing Address - Phone:817-773-2459
Mailing Address - Fax:
Practice Address - Street 1:7009 BRIERHOLLOW CT
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76132-7110
Practice Address - Country:US
Practice Address - Phone:817-773-2459
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-09-01
Last Update Date:2019-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX77027101YM0800X, 101YP2500X, 101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional