=====================================================
General NPI Number Information
=====================================================
NPI Number | 1740929058
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | UNTANGLIFE COUNSELING PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/03/2022
-----------------------------------------------------
Last Update Date | 06/03/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 6040 CAMP BOWIE BLVD
-----------------------------------------------------
City | FORT WORTH
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 76116-5612
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 817-968-1905
-----------------------------------------------------
Fax | 817-612-3371
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 6040 CAMP BOWIE BLVD
-----------------------------------------------------
City | FORT WORTH
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 76116-5612
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 817-968-1905
-----------------------------------------------------
Fax | 817-612-3371
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | ALISON BAILEY
-----------------------------------------------------
Credential | LMFT
-----------------------------------------------------
Telephone | 760-576-6963
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QM0801X
-----------------------------------------------------
Taxonomy Name | Mental Health Clinic/Center (Including Community Mental Health Center)
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------