MEDICARE: MS. AUTUMN RAE HENRY LCDC-I, LMSW

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	104100000X	Social Worker	116883	TX

General Provider Information

NPI Number	:	1326997214
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. AUTUMN RAE HENRY LCDC-I, LMSW

Provider Business Mailing Address
First Line	:	2601 SCOTT AVE STE 402
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76103-2333
Country	:	US
Telephone Number	:	682-359-6167
Fax Number	:

Provider Business Practice Location Address
First Line	:	2601 SCOTT AVE STE 402
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76103-2333
Country	:	US
Telephone Number	:	682-359-6167
Fax Number	:

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

Provider Enumeration Date	:	01/24/2026
Last Update Date	:	01/24/2026

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