1891340386 NPI number — LIGHT BRIGHT COUNSELING CENTER, PLLC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1891340386 NPI number — LIGHT BRIGHT COUNSELING CENTER, PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
LIGHT BRIGHT COUNSELING CENTER, PLLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1891340386
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/02/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
10416 BOXTHORN CT
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FORT WORTH
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
76177-3012
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
817-675-1074
Provider Business Mailing Address Fax Number:
682-708-0501

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1751 RIVER RUN STE 200
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FORT WORTH
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
76107-6670
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
682-253-6810
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
08/02/2019

Additional Information

Authorized Official

Authorized Official Last Name:
GRAY
Authorized Official First Name:
CHERYL
Authorized Official Middle Name:
V.
Authorized Official Title or Position:
THERAPIST
Authorized Official Telephone Number:
817-675-1074

Provider Taxonomy Codes

  • Taxonomy code: 101YP2500X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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