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General NPI Number Information
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NPI Number | 1124455571
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Entity Type | Organization
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Legal Business Name | POSITIVE IMPACT THERAPEUTIC SERVICES
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Dates
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Enumeration Date | 10/01/2013
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Last Update Date | 10/01/2013
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Provider Practice Location Address
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Address Line | 12650 N BEACH ST STE 114
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City | FORT WORTH
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State | TX
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Zip | 76244-4245
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Country | US
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Telephone | 832-338-4711
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Fax |
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Provider Business Mailing Address
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Address Line | 12650 N BEACH ST STE 114
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City | FORT WORTH
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State | TX
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Zip | 76244-4245
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | ADMINISTRATOR
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Name | MARNEE CRUTCHFIELD
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Credential |
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Telephone | 832-338-4711
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YP2500X
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Taxonomy Name | Professional Counselor
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License Number | 19337
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License Number State | TX
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