MEDICARE: BRAINSTORM LEARNING

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	103T00000X	Psychologist	36708	TX
2	103T00000X	Psychologist	15507	TX

General Provider Information

NPI Number	:	1881071116
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BRAINSTORM LEARNING

Provider Business Mailing Address
First Line	:	1208 W MAGNOLIA AVE
Second Line	:	SUITE 234
City	:	FORT WORTH
State	:	TX
Zip	:	76104-4472
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1208 W MAGNOLIA AVE
Second Line	:	SUITE 234
City	:	FORT WORTH
State	:	TX
Zip	:	76104-4472
Country	:	US
Telephone Number	:	817-501-7363
Fax Number	:

Authorized Official
Title or Position	:	CO-OWNER
Name	:	DR. JODI LOWTHER
Credential	:
Telephone Number	:	817-501-7363

Provider Enumeration Date	:	05/06/2015
Last Update Date	:	05/06/2015

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Directions to “BRAINSTORM LEARNING ” Practice Location

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