MEDICARE: GENNA L KEGLEY M.S., L.P.C.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YP2500X	Professional Counselor	20133	TX

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	20133	OTHER	TX	TEXAS STATE BOARD OF EXAMINERS OF PROFESSIONAL COUNSELORS

General Provider Information

NPI Number	:	1073621678
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	GENNA L KEGLEY M.S., L.P.C.

Provider Business Mailing Address
First Line	:	101 REDWATER RD APT 289
Second Line	:
City	:	WAKE VILLAGE
State	:	TX
Zip	:	75501-5747
Country	:	US
Telephone Number	:	817-542-2240
Fax Number	:

Provider Business Practice Location Address
First Line	:	6017 REEF POINT LN STE 135
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76135-7006
Country	:	US
Telephone Number	:	817-542-2240
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/25/2006
Last Update Date	:	12/24/2020

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