Provider Demographics
NPI:1982319992
Name:KICK IN THE ASS COUNSELING
Entity type:Organization
Organization Name:KICK IN THE ASS COUNSELING
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:AUTHORIZED OFFICIAL
Authorized Official - Prefix:
Authorized Official - First Name:VICTORIA
Authorized Official - Middle Name:
Authorized Official - Last Name:GONZALES
Authorized Official - Suffix:
Authorized Official - Credentials:LPC
Authorized Official - Phone:817-495-9776
Mailing Address - Street 1:4200 SOUTH FWY STE 520
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76115-1406
Mailing Address - Country:US
Mailing Address - Phone:817-495-9776
Mailing Address - Fax:
Practice Address - Street 1:4200 SOUTH FWY STE 520
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76115-1406
Practice Address - Country:US
Practice Address - Phone:817-495-9776
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-01-16
Last Update Date:2024-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX86035OtherLPC LICENSE