Healthcare Provider Details

I. General information

NPI: 1114477403
Provider Name (Legal Business Name): TAMMI EVANS WITHERSPOON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/11/2016
Last Update Date: 10/14/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1119 W PIONEER PKWY SUITE 115
ARLINGTON TX
76013-7604
US

IV. Provider business mailing address

1119 W PIONEER PKWY SUITE 115
ARLINGTON TX
76013-7604
US

V. Phone/Fax

Practice location:
  • Phone: 682-238-3831
  • Fax: 817-274-1900
Mailing address:
  • Phone: 682-238-3831
  • Fax: 817-274-1900

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number StateTX
# 3
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number StateTX
# 4
Primary TaxonomyN
Taxonomy Code101YP1600X
TaxonomyPastoral Counselor
License Number
License Number StateTX
# 5
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number
License Number StateTX
# 6
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number
License Number StateTX
# 7
Primary TaxonomyN
Taxonomy Code320800000X
TaxonomyMental Illness Community Based Residential Treatment Facility
License Number
License Number StateTX
# 8
Primary TaxonomyN
Taxonomy Code320900000X
TaxonomyIntellectual and/or Developmental Disabilities Community Based Residential Treatment Facility
License Number
License Number StateTX
# 9
Primary TaxonomyN
Taxonomy Code320600000X
TaxonomyIntellectual and/or Developmental Disabilities Residential Treatment Facility
License Number
License Number StateTX
# 10
Primary TaxonomyN
Taxonomy Code324500000X
TaxonomySubstance Abuse Rehabilitation Facility
License Number
License Number StateTX
# 11
Primary TaxonomyN
Taxonomy Code322D00000X
TaxonomyEmotionally Disturbed Childrens' Residential Treatment Facility
License Number
License Number StateTX
# 12
Primary TaxonomyN
Taxonomy Code273R00000X
TaxonomyPsychiatric Hospital Unit
License Number
License Number StateTX
# 13
Primary TaxonomyN
Taxonomy Code282J00000X
TaxonomyReligious Nonmedical Health Care Institution
License Number
License Number StateTX
# 14
Primary TaxonomyN
Taxonomy Code284300000X
TaxonomySpecial Hospital
License Number
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: