1376606301 NPI number — DR. LINDA TEAL WILLOUGHBY PHD LPC

Table of content: DR. LINDA TEAL WILLOUGHBY PHD LPC (NPI 1376606301)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1376606301 NPI number — DR. LINDA TEAL WILLOUGHBY PHD LPC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WILLOUGHBY
Provider First Name:
LINDA
Provider Middle Name:
TEAL
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
PHD LPC
Provider Gender Code:
F

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:
1376606301
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1600 AIRPORT FWY
Provider Second Line Business Mailing Address:
SUITE 334
Provider Business Mailing Address City Name:
BEDFORD
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
76022-6850
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
817-571-7400
Provider Business Mailing Address Fax Number:
817-571-7406

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1600 AIRPORT FWY
Provider Second Line Business Practice Location Address:
SUITE 334
Provider Business Practice Location Address City Name:
BEDFORD
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
76022-6850
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
817-571-7400
Provider Business Practice Location Address Fax Number:
817-571-7406
Provider Enumeration Date:
12/19/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 101YM0800X , with the licence number:  LPC 12328 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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