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General NPI Number Information
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NPI Number | 1720775166
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Entity Type | Organization
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Legal Business Name | FORT WORTH PSYCHWORKS, PLLC
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Dates
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Enumeration Date | 04/18/2023
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Last Update Date | 04/23/2023
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Provider Practice Location Address
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Address Line | 300 COLLEGE AVE
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City | FORT WORTH
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State | TX
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Zip | 76104-1121
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Country | US
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Telephone | 873-349-7646
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Fax |
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Provider Business Mailing Address
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Address Line | 1704 6TH AVE
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City | FT WORTH
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State | TX
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Zip | 76110-6401
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Country | US
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Telephone | 502-775-9063
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | JUSTIN GADDIS
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Credential | PHD
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Telephone | 817-349-7646
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 103T00000X
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Taxonomy Name | Psychologist
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 261QM0801X
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Taxonomy Name | Mental Health Clinic/Center (Including Community Mental Health Center)
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License Number |
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License Number State |
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Taxonomy #3
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Taxonomy Code | 261QM0850X
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Taxonomy Name | Adult Mental Health Clinic/Center
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License Number |
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License Number State |
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Taxonomy #4
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Taxonomy Code | 261QM0855X
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Taxonomy Name | Adolescent and Children Mental Health Clinic/Center
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License Number |
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License Number State |
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