Provider Demographics
NPI:1457631616
Name:HARTFORD, METALISA JOYCE (LBSW)
Entity Type:Individual
Prefix:
First Name:METALISA
Middle Name:JOYCE
Last Name:HARTFORD
Suffix:
Gender:F
Credentials:LBSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2409 CHARBONEAU DR
Mailing Address - Street 2:
Mailing Address - City:WACO
Mailing Address - State:TX
Mailing Address - Zip Code:76710-1105
Mailing Address - Country:US
Mailing Address - Phone:254-235-1969
Mailing Address - Fax:
Practice Address - Street 1:2409 CHARBONEAU DR
Practice Address - Street 2:
Practice Address - City:WACO
Practice Address - State:TX
Practice Address - Zip Code:76710-1105
Practice Address - Country:US
Practice Address - Phone:254-235-1969
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-08-19
Last Update Date:2011-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX15367171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator