MEDICARE: KANDRA D SHORTER LMFT

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	106H00000X	Marriage & Family Therapist	203858	TX

General Provider Information

NPI Number	:	1801508122
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KANDRA D SHORTER LMFT

Provider Business Mailing Address
First Line	:	2332 BEVERLY HILLS DR
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76114-1756
Country	:	US
Telephone Number	:	817-625-4254
Fax Number	:	817-378-0861

Provider Business Practice Location Address
First Line	:	2909 MITCHELL BLVD
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76105-4642
Country	:	US
Telephone Number	:	817-625-4254
Fax Number	:	817-378-0861

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

Provider Enumeration Date	:	12/19/2022
Last Update Date	:	08/21/2023

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