Provider Demographics
NPI:1356417877
Name:FORTENBERRY, MELODY ANN (PHD)
Entity type:Individual
Prefix:DR
First Name:MELODY
Middle Name:ANN
Last Name:FORTENBERRY
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5757 ALPHA RD
Mailing Address - Street 2:SUITE 209
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75240-4601
Mailing Address - Country:US
Mailing Address - Phone:972-458-9890
Mailing Address - Fax:972-458-9890
Practice Address - Street 1:5757 ALPHA RD
Practice Address - Street 2:SUITE 209
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75240-4601
Practice Address - Country:US
Practice Address - Phone:972-458-9890
Practice Address - Fax:972-458-9890
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX22645103T00000X, 103TC0700X, 103TC2200X, 103TF0000X, 103TP2701X
TX570106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered103T00000XBehavioral Health & Social Service ProvidersPsychologist
Not Answered103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Not Answered103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent
Not Answered103TF0000XBehavioral Health & Social Service ProvidersPsychologistFamily
Not Answered103TP2701XBehavioral Health & Social Service ProvidersPsychologistGroup Psychotherapy
Not Answered106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX00D39ROtherBLUE CROSS BLUE SHIELD