Provider Demographics
NPI:1730215724
Name:FORT WORTH BRIEF THERAPY CENTER
Entity type:Organization
Organization Name:FORT WORTH BRIEF THERAPY CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CO-DIRECTOR, ASSOCIATE THERAPIST
Authorized Official - Prefix:MR
Authorized Official - First Name:ELLIOTT
Authorized Official - Middle Name:EUGENE
Authorized Official - Last Name:CONNIE
Authorized Official - Suffix:
Authorized Official - Credentials:LPC-I
Authorized Official - Phone:817-870-1080
Mailing Address - Street 1:1400 S MAIN ST
Mailing Address - Street 2:SUITE 509
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76104-4909
Mailing Address - Country:US
Mailing Address - Phone:817-870-1080
Mailing Address - Fax:817-870-1085
Practice Address - Street 1:1400 S MAIN ST
Practice Address - Street 2:SUITE 509
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76104-4909
Practice Address - Country:US
Practice Address - Phone:817-870-1080
Practice Address - Fax:817-870-1085
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-26
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX62681101Y00000X, 101YM0800X, 101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Not Answered101Y00000XBehavioral Health & Social Service ProvidersCounselorGroup - Multi-Specialty
Not Answered101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
Not Answered101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty