MEDICARE: SHEWANNA LAGALE GILES LCSW

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	15150	TX

General Provider Information

NPI Number	:	1093395162
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SHEWANNA LAGALE GILES LCSW

Provider Business Mailing Address
First Line	:	PO BOX 60441
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76115-6441
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	2125 DENIRO DR
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76134-4154
Country	:	US
Telephone Number	:	817-909-2715
Fax Number	:

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

Provider Enumeration Date	:	04/12/2021
Last Update Date	:	04/12/2021

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