=====================================================
General NPI Number Information
=====================================================
NPI Number | 1760125397
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | CARY LINZY COUNSELOR
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/20/2022
-----------------------------------------------------
Last Update Date | 04/20/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 7901 OCEAN DR
-----------------------------------------------------
City | FORT WORTH
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 76123-1815
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 817-559-4841
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 35131
-----------------------------------------------------
City | FORT WORTH
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 76162-5131
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 817-559-4841
-----------------------------------------------------
Fax | 817-349-9211
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251E00000X
-----------------------------------------------------
Taxonomy Name | Home Health Agency
-----------------------------------------------------
License Number | 021209
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------