=====================================================
General NPI Number Information
=====================================================
NPI Number | 1902410756
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | COWTOWN COUNSELING PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/31/2020
-----------------------------------------------------
Last Update Date | 08/31/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3270 MARYS LN
-----------------------------------------------------
City | FORT WORTH
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 76116-4328
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 817-891-2886
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3270 MARYS LN
-----------------------------------------------------
City | FORT WORTH
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 76116-4328
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 817-891-2886
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | LICENSED CLINICAL SOCIAL WORKER
-----------------------------------------------------
Name | SIOBHAN BEATY
-----------------------------------------------------
Credential | LCSW
-----------------------------------------------------
Telephone | 817-891-2886
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------