=====================================================
General NPI Number Information
=====================================================
NPI Number | 1962167270
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | CHELSEA PETTY MS, LMFT-A
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/02/2021
-----------------------------------------------------
Last Update Date | 03/07/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 6115 CAMP BOWIE BLVD STE 220
-----------------------------------------------------
City | FORT WORTH
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 76116-5543
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 817-381-0633
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5440 HARVEST HILL RD STE 230
-----------------------------------------------------
City | DALLAS
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75230-6424
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 512-710-7075
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 106H00000X
-----------------------------------------------------
Taxonomy Name | Marriage & Family Therapist
-----------------------------------------------------
License Number | 204007
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------