Healthcare Provider Details

I. General information

NPI: 1437450780
Provider Name (Legal Business Name): MICHAEL COREY BEARDEN LPC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/03/2010
Last Update Date: 10/25/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1810 8TH AVE SUITE A
FORT WORTH TX
76110-1352
US

IV. Provider business mailing address

2209 EDWIN ST
FORT WORTH TX
76110-1215
US

V. Phone/Fax

Practice location:
  • Phone: 817-897-7247
  • Fax: 817-549-0293
Mailing address:
  • Phone: 817-897-7247
  • Fax: 817-549-0293

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number66256
License Number StateTX
# 2
Primary TaxonomyN
Taxonomy Code101YP1600X
TaxonomyPastoral Counselor
License Number66256
License Number StateTX
# 3
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number66256
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: