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General NPI Number Information
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NPI Number | 1487917274
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Entity Type | Organization
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Legal Business Name | SOUTHSTAR COUNSELING LLC
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Dates
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Enumeration Date | 06/18/2012
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Last Update Date | 06/18/2012
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Provider Practice Location Address
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Address Line | 4204 STAGHORN CIR N
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City | FORT WORTH
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State | TX
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Zip | 76137-1121
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Country | US
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Telephone | 817-705-0543
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Fax | 817-386-7623
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Provider Business Mailing Address
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Address Line | PO BOX 2512
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City | FORT WORTH
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State | TX
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Zip | 76113-2512
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Country | US
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Telephone | 817-705-0543
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Fax | 817-386-7623
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Authorized Official
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Title or Position | PRESIDENT
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Name | MR. CARL G CORDOVA
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Credential | LCSW
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Telephone | 817-705-0543
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1041C0700X
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Taxonomy Name | Clinical Social Worker
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License Number | 51542
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License Number State | TX
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