MEDICARE: MRS. KIMBERLY C SCALES LPC

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	101YA0400X	Addiction (Substance Use Disorder) Counselor	9710	TX
2	101YP2500X	Professional Counselor	65248	TX

General Provider Information

NPI Number	:	1063848786
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. KIMBERLY C SCALES LPC

Provider Business Mailing Address
First Line	:	6320 BRENTWOOD STAIR RD
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76112-3136
Country	:	US
Telephone Number	:	817-548-9990
Fax Number	:	817-446-9770

Provider Business Practice Location Address
First Line	:	6320 BRENTWOOD STAIR RD
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76112-3136
Country	:	US
Telephone Number	:	817-548-9990
Fax Number	:	817-446-9770

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

Provider Enumeration Date	:	09/26/2013
Last Update Date	:	09/26/2013

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