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2435 E Southlake Blvd Ste 220 Southlake TX 76092-6678 | |
| (817) 228-1668 | |
| (469) 776-0669 |
| Full Name | |
|---|---|
| Speciality | Counselor - Professional |
| Location | 2435 E Southlake Blvd Ste 220, Southlake, Texas |
| Authorized Official Name and Position | Kelly Lynn Cheatham (PRESIDENT) |
| Authorized Official Contact | 8172281668 |
| Accepts Medicare Insurance | This clinic does not participate in Medicare Program. |
| Mailing Address | Practice Location Address |
|---|---|
2535 E Southlake Blvd Ste 220 Southlake TX 76092-6629 Ph: (817) 228-1668 | 2435 E Southlake Blvd Ste 220 Southlake TX 76092-6678 Ph: (817) 228-1668 |
| NPI Number | 1821687880 |
|---|---|
| Provider Enumeration Date | 01/14/2021 |
| Last Update Date | 01/03/2025 |
| Certification Date | 01/03/2025 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1821687880 | NPI | - | NPPES |
| Taxonomy | Type | License (State) | Status |
|---|---|---|---|
| 101YP2500X | Counselor - Professional | (* (Not Available)) | Primary |
| 1041C0700X | Social Worker - Clinical | (* (Not Available)) | Secondary |
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