MEDICARE: MATILDE TERESA BARKSDALE

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	171M00000X	Case Manager/Care Coordinator

General Provider Information

NPI Number	:	1003163155
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MATILDE TERESA BARKSDALE

Provider Business Mailing Address
First Line	:	5818 NW BECKHAM CT
Second Line	:
City	:	PORT SAINT LUCIE
State	:	FL
Zip	:	34986-4146
Country	:	US
Telephone Number	:	772-344-1958
Fax Number	:	772-344-1958

Provider Business Practice Location Address
First Line	:	5818 NW BECKHAM CT
Second Line	:
City	:	PORT SAINT LUCIE
State	:	FL
Zip	:	34986-4146
Country	:	US
Telephone Number	:	772-344-1958
Fax Number	:	772-344-1958

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/08/2012
Last Update Date	:	08/08/2012

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