Provider Demographics
NPI:1285252031
Name:GARCIA, KIERSTA LANE
Entity type:Individual
Prefix:MS
First Name:KIERSTA
Middle Name:LANE
Last Name:GARCIA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1810 8TH AVE STE B204
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76110-1352
Mailing Address - Country:US
Mailing Address - Phone:682-200-9484
Mailing Address - Fax:
Practice Address - Street 1:1810 8TH AVE STE B204
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76110-1352
Practice Address - Country:US
Practice Address - Phone:682-200-9484
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-07-08
Last Update Date:2020-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX80043101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional