Healthcare Provider Details

I. General information

NPI: 1023994217
Provider Name (Legal Business Name): TIANA KOYUKI GAYLORD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/13/2025
Last Update Date: 08/09/2026
Certification Date: 08/09/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

305 NE LOOP 820 STE 408
HURST TX
76053-7214
US

IV. Provider business mailing address

1508 AIRPORT FWY
BEDFORD TX
76022-6775
US

V. Phone/Fax

Practice location:
  • Phone: 817-562-6089
  • Fax:
Mailing address:
  • Phone: 972-838-5218
  • Fax: 972-838-5218

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number13178-C
License Number StateNV
# 2
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number110628
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: