MEDICARE: SOUTHSTAR COUNSELING LLC

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	51542	TX

General Provider Information

NPI Number	:	1487917274
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SOUTHSTAR COUNSELING LLC

Provider Business Mailing Address
First Line	:	PO BOX 2512
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76113-2512
Country	:	US
Telephone Number	:	817-705-0543
Fax Number	:	817-386-7623

Provider Business Practice Location Address
First Line	:	4204 STAGHORN CIR N
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76137-1121
Country	:	US
Telephone Number	:	817-705-0543
Fax Number	:	817-386-7623

Authorized Official
Title or Position	:	PRESIDENT
Name	:	MR. CARL G CORDOVA
Credential	:	LCSW
Telephone Number	:	817-705-0543

Provider Enumeration Date	:	06/18/2012
Last Update Date	:	06/18/2012

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