Provider Demographics
NPI:1144867821
Name:VALHALLA WELLNESS
Entity type:Organization
Organization Name:VALHALLA WELLNESS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/LPC
Authorized Official - Prefix:
Authorized Official - First Name:TERESA
Authorized Official - Middle Name:
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:682-708-3460
Mailing Address - Street 1:8551 BOAT CLUB RD
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76179-3638
Mailing Address - Country:US
Mailing Address - Phone:682-708-3460
Mailing Address - Fax:682-708-3121
Practice Address - Street 1:8551 BOAT CLUB RD
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76179-3638
Practice Address - Country:US
Practice Address - Phone:682-708-3460
Practice Address - Fax:682-708-3121
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-12-02
Last Update Date:2019-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1194244525Medicaid