Healthcare Provider Details

I. General information

NPI: 1790141745
Provider Name (Legal Business Name): COLWICK COUNSELING
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/06/2016
Last Update Date: 01/06/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1400 W. NORTHWEST HIGHWAY SUITE 260
GRAPEVINE TX
76051
US

IV. Provider business mailing address

1400 W. NORTHWEST HIGHWAY SUITE 260
GRAPEVINE TX
76051
US

V. Phone/Fax

Practice location:
  • Phone: 817-760-0333
  • Fax:
Mailing address:
  • Phone: 817-760-0333
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number201959
License Number StateTX
# 2
Primary TaxonomyN
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number201959
License Number StateTX
# 3
Primary TaxonomyN
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number201959
License Number StateTX

VIII. Authorized Official

Name: KATRINA JEANETTE WILL
Title or Position: OWNER
Credential: LMFT
Phone: 817-760-0333