Healthcare Provider Details

I. General information

NPI: 1053645283
Provider Name (Legal Business Name): MINDY NICOLE HARRISON LMSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/21/2009
Last Update Date: 10/15/2021
Certification Date: 10/15/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

801 7TH AVE
FORT WORTH TX
76104-2733
US

IV. Provider business mailing address

PO BOX 99213
FORT WORTH TX
76199-0213
US

V. Phone/Fax

Practice location:
  • Phone: 682-885-3878
  • Fax: 682-885-1672
Mailing address:
  • Phone: 682-885-4871
  • Fax: 682-885-3936

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number38536
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: