Healthcare Provider Details

I. General information

NPI: 1285892489
Provider Name (Legal Business Name): CLENDON HENRY PURNELL JR. LPC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

Provider Other Name: J.R. PURNELL LPC

II. Dates (important events)

Enumeration Date: 05/26/2008
Last Update Date: 05/26/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7525 JOHN T WHITE RD
FORT WORTH TX
76120-3311
US

IV. Provider business mailing address

7525 JOHN T WHITE RD
FORT WORTH TX
76120-3311
US

V. Phone/Fax

Practice location:
  • Phone: 817-429-4769
  • Fax: 817-457-7906
Mailing address:
  • Phone: 817-429-4769
  • Fax: 817-457-7906

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number61286
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: