MEDICARE: INNER CITY RECOVERY AND BEHAVIORAL HEALTH LLC

Medicare Provider Information

Scope of Practice

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

#	Taxonomy Code	Taxonomy
1	101YA0400X	Addiction (Substance Use Disorder) Counselor
2	101YP2500X	Professional Counselor
3	103TB0200X	Cognitive & Behavioral Psychologist
4	261QM0801X	Mental Health Clinic/Center (Including Community Mental Health Center)
5	261QM0850X	Adult Mental Health Clinic/Center
6	251B00000X	Case Management Agency

General Provider Information

NPI Number	:	1982367603
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	INNER CITY RECOVERY AND BEHAVIORAL HEALTH LLC

Provider Business Mailing Address
First Line	:	4817 BRENTWOOD STAIR RD STE 105
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76103-1734
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	4817 BRENTWOOD STAIR RD STE 105
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76103-1734
Country	:	US
Telephone Number	:	214-228-3072
Fax Number	:

Authorized Official
Title or Position	:	MANAGER
Name	:	NICOLE WASHINGTON
Credential	:
Telephone Number	:	214-228-3072

Provider Enumeration Date	:	10/19/2021
Last Update Date	:	11/28/2022

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