Healthcare Provider Details

I. General information

NPI: 1700882339
Provider Name (Legal Business Name): KATHRYN WORTZ PHD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/28/2005
Last Update Date: 09/19/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11937 US HIGHWAY 271
TYLER TX
75708-3154
US

IV. Provider business mailing address

11937 US HIGHWAY 271
TYLER TX
75708-3154
US

V. Phone/Fax

Practice location:
  • Phone: 903-877-7248
  • Fax: 903-877-7778
Mailing address:
  • Phone: 903-877-7248
  • Fax: 903-877-7778

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number23861
License Number StateTX
# 2
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberPSY 703
License Number StateHI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: