Provider Demographics
NPI:1306738901
Name:CARLISLE, KENNETH
Entity type:Individual
Prefix:
First Name:KENNETH
Middle Name:
Last Name:CARLISLE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5201 MCCART AVE STE H
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76115-3700
Mailing Address - Country:US
Mailing Address - Phone:817-761-7692
Mailing Address - Fax:
Practice Address - Street 1:5201 MCCART AVE STE H
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76115-3700
Practice Address - Country:US
Practice Address - Phone:817-761-7692
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-07-17
Last Update Date:2025-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health