Basic Information
| Provider Information | |||||||||
| NPI: | 1407842578 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | FAMILY DYNAMICS INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 12850 HILLCREST RD | ||||||||
| Address2: | SUITE F-206 | ||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 752301529 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9724048253 | ||||||||
| FaxNumber: | 9727010874 | ||||||||
| Practice Location | |||||||||
| Address1: | 12850 HILLCREST RD | ||||||||
| Address2: | SUITE F-206 | ||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 752301529 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9724048253 | ||||||||
| FaxNumber: | 9727010874 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/23/2005 | ||||||||
| LastUpdateDate: | 09/29/2010 | ||||||||
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| AuthorizedOfficialLastName: | DURHAM | ||||||||
| AuthorizedOfficialFirstName: | MARY | ||||||||
| AuthorizedOfficialMiddleName: | ELLEN | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 9724048253 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | LCSW-ACP, LMFT | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 104100000X | 2443 | TX | Y | 193400000X SINGLE SPECIALTY GROUP | Behavioral Health & Social Service Providers | Social Worker |
ID Information
| ID | Type | State | Issuer | Description | 06MR | 01 | TX | BCBS | OTHER |