Provider Demographics
NPI:1528333044
Name:ILLINGWORTH, ENRIQUE (LMSW)
Entity type:Individual
Prefix:
First Name:ENRIQUE
Middle Name:
Last Name:ILLINGWORTH
Suffix:
Gender:M
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2416 FM 2280
Mailing Address - Street 2:
Mailing Address - City:CLEBURNE
Mailing Address - State:TX
Mailing Address - Zip Code:76031
Mailing Address - Country:US
Mailing Address - Phone:817-526-4862
Mailing Address - Fax:
Practice Address - Street 1:2700 MEACHAM BLVD
Practice Address - Street 2:SUITE 100
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76137
Practice Address - Country:US
Practice Address - Phone:817-984-8525
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-03-16
Last Update Date:2012-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX37644104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker