MEDICARE: FEYDRA GORSLINE LCSW

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	1041C0700X	Clinical Social Worker	60411	TX

General Provider Information

NPI Number	:	1982381661
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	FEYDRA GORSLINE LCSW

Provider Business Mailing Address
First Line	:	9321 WOOD DUCK DR
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76118-7785
Country	:	US
Telephone Number	:	817-368-7861
Fax Number	:

Provider Business Practice Location Address
First Line	:	9321 WOOD DUCK DR
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76118-7785
Country	:	US
Telephone Number	:	817-368-7861
Fax Number	:

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

Provider Enumeration Date	:	07/03/2023
Last Update Date	:	07/03/2023

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