Provider Demographics
NPI:1669621009
Name:GARCIA, IRASEMA (LPC)
Entity type:Individual
Prefix:
First Name:IRASEMA
Middle Name:
Last Name:GARCIA
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1196 VERDE OAKS LN
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76135-9034
Mailing Address - Country:US
Mailing Address - Phone:817-992-0410
Mailing Address - Fax:817-237-9592
Practice Address - Street 1:3301 HAMILTON AVE
Practice Address - Street 2:SUITE 104
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76107-1898
Practice Address - Country:US
Practice Address - Phone:817-992-0410
Practice Address - Fax:817-237-9592
Is Sole Proprietor?:Yes
Enumeration Date:2008-09-10
Last Update Date:2011-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX62036101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX197124402Medicaid