MEDICARE: RECREATION THERAPY SERVICE

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	261QM0850X	Adult Mental Health Clinic/Center	26735	TX

General Provider Information

NPI Number	:	1265615827
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	RECREATION THERAPY SERVICE

Provider Business Mailing Address
First Line	:	6000 WESTERN PL
Second Line	:	300
City	:	FORT WORTH
State	:	TX
Zip	:	76107-4607
Country	:	US
Telephone Number	:	817-570-2230
Fax Number	:	817-570-2231

Provider Business Practice Location Address
First Line	:	6000 WESTERN PL
Second Line	:	300
City	:	FORT WORTH
State	:	TX
Zip	:	76107-4607
Country	:	US
Telephone Number	:	817-570-2230
Fax Number	:	817-570-2231

Authorized Official
Title or Position	:	RECREATION THERAPY SPECIALIST
Name	:	MS. DONNA LEWIS GERRON
Credential	:	CTRS
Telephone Number	:	817-570-2230

Provider Enumeration Date	:	12/06/2007
Last Update Date	:	12/06/2007

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