MEDICARE: AMISTIC WILTZ 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	17427	LA
2	1041C0700X	Clinical Social Worker
3	1041C0700X	Clinical Social Worker	61904	TX

General Provider Information

NPI Number	:	1114691474
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	AMISTIC WILTZ LCSW

Provider Business Mailing Address
First Line	:	4518 SHALLOW HILL CT
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77084-7895
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	4518 SHALLOW HILL CT
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77084-7895
Country	:	US
Telephone Number	:	346-327-4955
Fax Number	:

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

Provider Enumeration Date	:	08/02/2021
Last Update Date	:	09/28/2022

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Directions to “ AMISTIC WILTZ LCSW” Practice Location

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