=====================================================
General NPI Number Information
=====================================================
NPI Number | 1134322209
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | GARY T ONGLEY LPC, LCSW
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/07/2007
-----------------------------------------------------
Last Update Date | 09/30/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1901 CENTRAL DR STE 315
-----------------------------------------------------
City | BEDFORD
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 76021-5869
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 817-919-7351
-----------------------------------------------------
Fax | 817-684-9979
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2716 RANCHVIEW DR
-----------------------------------------------------
City | BURLESON
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 76028-1534
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 817-919-7351
-----------------------------------------------------
Fax | 817-336-1740
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | S14689
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 101YP2500X
-----------------------------------------------------
Taxonomy Name | Professional Counselor
-----------------------------------------------------
License Number | 9401
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------