Healthcare Provider Details

I. General information

NPI: 1831890433
Provider Name (Legal Business Name): KYLIE IZIENICKI LPC-ASSOCIATE 100532
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/13/2023
Last Update Date: 08/13/2026
Certification Date: 08/13/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4545 BELLAIRE DR S STE 6
FORT WORTH TX
76109-1811
US

IV. Provider business mailing address

1206 LOGIE LN
FORT WORTH TX
76134-5479
US

V. Phone/Fax

Practice location:
  • Phone: 817-657-1115
  • Fax:
Mailing address:
  • Phone: 720-988-6013
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number100532
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: