MEDICARE: MRS. LAURA KAY BRANNAN LCSW

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	1041C0700X	Clinical Social Worker	14569	TX

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	241678	OTHER	TX	AMERIGROUP TEXAS

General Provider Information

NPI Number	:	1053426544
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. LAURA KAY BRANNAN LCSW

Provider Business Mailing Address
First Line	:	1160 COUNTRY CLUB LN
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76112-2303
Country	:	US
Telephone Number	:	817-457-0682
Fax Number	:	817-451-4104

Provider Business Practice Location Address
First Line	:	1160 COUNTRY CLUB LN
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76112-2303
Country	:	US
Telephone Number	:	817-457-0682
Fax Number	:	817-451-4104

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

Provider Enumeration Date	:	08/21/2006
Last Update Date	:	03/28/2019

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