MEDICARE: MS. RENESE ANN SUPER 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	56590	TX

General Provider Information

NPI Number	:	1336777010
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. RENESE ANN SUPER LCSW

Provider Business Mailing Address
First Line	:	12333 RED BIRCH LN
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76244-4597
Country	:	US
Telephone Number	:	817-403-1298
Fax Number	:

Provider Business Practice Location Address
First Line	:	12333 RED BIRCH LN
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76244-4597
Country	:	US
Telephone Number	:	817-403-1298
Fax Number	:

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

Provider Enumeration Date	:	03/30/2020
Last Update Date	:	03/30/2020

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