Provider Demographics
NPI:1992207856
Name:WARREN, DETRAE EUGENE (LPC)
Entity Type:Individual
Prefix:
First Name:DETRAE
Middle Name:EUGENE
Last Name:WARREN
Suffix:
Gender:M
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3704 GRIGGS AVE
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76119-2018
Mailing Address - Country:US
Mailing Address - Phone:817-565-6417
Mailing Address - Fax:
Practice Address - Street 1:1307 8TH AVE STE 310
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76104-4140
Practice Address - Country:US
Practice Address - Phone:817-851-2042
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-03-06
Last Update Date:2018-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX68544101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional