MEDICARE: MS. MONTEZ WILLA THOMASSON MSW

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		FL

General Provider Information

NPI Number	:	1003164138
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. MONTEZ WILLA THOMASSON MSW

Provider Business Mailing Address
First Line	:	1925 S PERIMETER RD
Second Line	:
City	:	FORT LAUDERDALE
State	:	FL
Zip	:	33309-7122
Country	:	US
Telephone Number	:	954-958-0988
Fax Number	:

Provider Business Practice Location Address
First Line	:	1925 S PERIMETER RD
Second Line	:
City	:	FORT LAUDERDALE
State	:	FL
Zip	:	33309-7122
Country	:	US
Telephone Number	:	954-958-0988
Fax Number	:

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

Provider Enumeration Date	:	08/21/2012
Last Update Date	:	08/21/2012

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