Healthcare Provider Details

I. General information

NPI: 1821794397
Provider Name (Legal Business Name): DAPHNE REYNOLDS LCDC-I
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/06/2023
Last Update Date: 02/06/2023
Certification Date: 02/06/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

700 HEMPHILL ST STE A
FT WORTH TX
76104-3105
US

IV. Provider business mailing address

700 HEMPHILL ST STE A
FT WORTH TX
76104-3105
US

V. Phone/Fax

Practice location:
  • Phone: 817-334-0111
  • Fax:
Mailing address:
  • Phone: 817-334-0111
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number55252
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: