Provider Demographics
NPI:1427306828
Name:TAVAKOLDAVANI, MELISSA LAYNE (LPC)
Entity type:Individual
Prefix:
First Name:MELISSA
Middle Name:LAYNE
Last Name:TAVAKOLDAVANI
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5751 KROGER DR
Mailing Address - Street 2:SUITE 269
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76244-5632
Mailing Address - Country:US
Mailing Address - Phone:817-812-2880
Mailing Address - Fax:
Practice Address - Street 1:5751 KROGER DR
Practice Address - Street 2:SUITE 269
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76244-5632
Practice Address - Country:US
Practice Address - Phone:817-812-2880
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-08-16
Last Update Date:2012-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX65472101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health