MEDICARE: CANVAS OUTPATIENT, PLLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy
1	261QM0855X	Adolescent and Children Mental Health Clinic/Center
2	251S00000X	Community/Behavioral Health Agency
3	101YM0800X	Mental Health Counselor

General Provider Information

NPI Number	:	1568144723
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CANVAS OUTPATIENT, PLLC

Provider Business Mailing Address
First Line	:	5521 BELLAIRE DR S STE 114
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76109-5855
Country	:	US
Telephone Number	:	817-394-2346
Fax Number	:	817-520-8520

Provider Business Practice Location Address
First Line	:	5521 BELLAIRE DR S STE 114
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76109-5855
Country	:	US
Telephone Number	:	817-394-2346
Fax Number	:	817-520-8520

Authorized Official
Title or Position	:	OWNER/DIRECTOR
Name	:	MR. ASHLEY STAFFORD
Credential	:	LCSW-S
Telephone Number	:	214-674-0798

Provider Enumeration Date	:	08/07/2023
Last Update Date	:	02/03/2026

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