Healthcare Provider Details

I. General information

NPI: 1699434530
Provider Name (Legal Business Name): MAMIE LEANN FLYNN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MAMIE LEANN HICKS,LOISELLE

II. Dates (important events)

Enumeration Date: 12/08/2021
Last Update Date: 12/08/2021
Certification Date: 12/08/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3840 HULEN ST
FORT WORTH TX
76107-7277
US

IV. Provider business mailing address

PO BOX 2603
FORT WORTH TX
76113-2603
US

V. Phone/Fax

Practice location:
  • Phone: 817-335-3022
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: