MEDICARE: EASTER SEALS NORTH TEXAS INC.

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
2	251B00000X	Case Management Agency

General Provider Information

NPI Number	:	1376751404
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	EASTER SEALS NORTH TEXAS INC.

Provider Business Mailing Address
First Line	:	633 3RD AVE FL 6
Second Line	:
City	:	NEW YORK
State	:	NY
Zip	:	10017-6733
Country	:	US
Telephone Number	:	817-542-1988
Fax Number	:	817-303-9274

Provider Business Practice Location Address
First Line	:	6900 ANDERSON BLVD STE 104
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76120-3030
Country	:	US
Telephone Number	:	817-332-7171
Fax Number	:	817-665-0878

Authorized Official
Title or Position	:	CFO
Name	:	CAROL KHOURY
Credential	:
Telephone Number	:	212-727-4270

Provider Enumeration Date	:	05/21/2007
Last Update Date	:	10/22/2024

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