MEDICARE: ANDREW DUTTON LPC, LCDC

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	3245S0500X	Children's Substance Abuse Rehabilitation Facility	11953	TX
2	101YP2500X	Professional Counselor	72717	TX

General Provider Information

NPI Number	:	1679980031
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ANDREW DUTTON LPC, LCDC

Provider Business Mailing Address
First Line	:	4316 BILGLADE RD
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76109-5317
Country	:	US
Telephone Number	:	217-417-1059
Fax Number	:

Provider Business Practice Location Address
First Line	:	4316 BILGLADE RD
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76109-5317
Country	:	US
Telephone Number	:	217-417-1059
Fax Number	:

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

Provider Enumeration Date	:	07/17/2014
Last Update Date	:	06/05/2020

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