MEDICARE: IRMA MIRELES

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	251S00000X	Community/Behavioral Health Agency	51649	TX

General Provider Information

NPI Number	:	1306381827
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	IRMA MIRELES

Provider Business Mailing Address
First Line	:	9624 MARINER CIR
Second Line	:	APT 1206
City	:	FORT WORTH
State	:	TX
Zip	:	76179-3210
Country	:	US
Telephone Number	:	817-455-3944
Fax Number	:

Provider Business Practice Location Address
First Line	:	9624 MARINER CIR
Second Line	:	APT 1206
City	:	FORT WORTH
State	:	TX
Zip	:	76179-3210
Country	:	US
Telephone Number	:	817-455-3944
Fax Number	:

Authorized Official
Title or Position	:	THERAPIST
Name	:	MS. IRMA MIRELES
Credential	:	LCSW
Telephone Number	:	817-455-3944

Provider Enumeration Date	:	12/20/2016
Last Update Date	:	12/20/2016

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