Healthcare Provider Details

I. General information

NPI: 1902943939
Provider Name (Legal Business Name): ALEXANDRA TIQUE-MONTENEGRO LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: ALEXANDRA TIQUE

II. Dates (important events)

Enumeration Date: 01/31/2007
Last Update Date: 12/28/2022
Certification Date: 12/28/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

431 E STATE HIGHWAY 114 FL 1
SOUTHLAKE TX
76092-4412
US

IV. Provider business mailing address

2332 BEVERLY HILLS DR
FORT WORTH TX
76114-1756
US

V. Phone/Fax

Practice location:
  • Phone: 844-824-8775
  • Fax:
Mailing address:
  • Phone: 817-625-4254
  • Fax: 817-378-0861

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: