Provider Demographics
NPI:1194085506
Name:LAKE WORTH COUNSELING
Entity type:Organization
Organization Name:LAKE WORTH COUNSELING
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SUSAN
Authorized Official - Middle Name:
Authorized Official - Last Name:SCHLOSSER
Authorized Official - Suffix:
Authorized Official - Credentials:LPC
Authorized Official - Phone:682-556-9096
Mailing Address - Street 1:4516 BOAT CLUB RD
Mailing Address - Street 2:STE 106
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76135-7019
Mailing Address - Country:US
Mailing Address - Phone:682-556-9096
Mailing Address - Fax:817-238-8333
Practice Address - Street 1:4516 BOAT CLUB RD
Practice Address - Street 2:STE 106
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76135-7019
Practice Address - Country:US
Practice Address - Phone:682-556-9096
Practice Address - Fax:817-238-8333
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-05-18
Last Update Date:2015-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX17834101YM0800X
TX5110106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX206698701Medicare PIN