Provider Demographics
NPI:1720608540
Name:GREATER DALLAS SUPPORT ALLIANCE
Entity Type:Organization
Organization Name:GREATER DALLAS SUPPORT ALLIANCE
Other - Org Name:ANNIE'S COUNSELING
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:LEE
Authorized Official - Last Name:BOATRIGHT
Authorized Official - Suffix:
Authorized Official - Credentials:LPC
Authorized Official - Phone:469-249-2585
Mailing Address - Street 1:PO BOX 1350
Mailing Address - Street 2:
Mailing Address - City:FORNEY
Mailing Address - State:TX
Mailing Address - Zip Code:75126-1350
Mailing Address - Country:US
Mailing Address - Phone:972-521-6105
Mailing Address - Fax:
Practice Address - Street 1:2102 DORSEY DR
Practice Address - Street 2:
Practice Address - City:FORNEY
Practice Address - State:TX
Practice Address - Zip Code:75126-0925
Practice Address - Country:US
Practice Address - Phone:469-249-3585
Practice Address - Fax:469-249-3585
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:GREATER DALLAS SUPPORT ALLIANCE
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2020-04-22
Last Update Date:2020-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty
No171M00000XOther Service ProvidersCase Manager/Care CoordinatorGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX410883901Medicaid