Healthcare Provider Details

I. General information

NPI: 1265615827
Provider Name (Legal Business Name): RECREATION THERAPY SERVICE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/06/2007
Last Update Date: 12/06/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6000 WESTERN PL 300
FORT WORTH TX
76107-4607
US

IV. Provider business mailing address

6000 WESTERN PL 300
FORT WORTH TX
76107-4607
US

V. Phone/Fax

Practice location:
  • Phone: 817-570-2230
  • Fax: 817-570-2231
Mailing address:
  • Phone: 817-570-2230
  • Fax: 817-570-2231

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number26735
License Number StateTX

VIII. Authorized Official

Name: MS. DONNA LEWIS GERRON
Title or Position: RECREATION THERAPY SPECIALIST
Credential: CTRS
Phone: 817-570-2230