=====================================================
General NPI Number Information
=====================================================
NPI Number | 1528333044
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ENRIQUE ILLINGWORTH LMSW
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/16/2012
-----------------------------------------------------
Last Update Date | 03/16/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2700 MEACHAM BLVD SUITE 100
-----------------------------------------------------
City | FORT WORTH
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 76137
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 817-984-8525
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2416 FM 2280
-----------------------------------------------------
City | CLEBURNE
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 76031
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 817-526-4862
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 104100000X
-----------------------------------------------------
Taxonomy Name | Social Worker
-----------------------------------------------------
License Number | 37644
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------