MEDICARE: KELLY MARIE CHERRYHOMES COX CCLS

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	101Y00000X	Counselor	23670	TX

General Provider Information

NPI Number	:	1104400274
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KELLY MARIE CHERRYHOMES COX CCLS

Provider Business Mailing Address
First Line	:	6512 ROCKROSE TRL
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76123-1572
Country	:	US
Telephone Number	:	817-504-0657
Fax Number	:

Provider Business Practice Location Address
First Line	:	6512 ROCKROSE TRL
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76123-1572
Country	:	US
Telephone Number	:	817-504-0657
Fax Number	:

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

Provider Enumeration Date	:	05/05/2021
Last Update Date	:	05/05/2021

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