MEDICARE: JAMES HERSHEL SELF LMFT

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	106H00000X	Marriage & Family Therapist	948-945	TX

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	000948-000945	OTHER	TX	LMFT

General Provider Information

NPI Number	:	1134292170
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JAMES HERSHEL SELF LMFT

Provider Business Mailing Address
First Line	:	6130 RICHMOND AVE
Second Line	:
City	:	DALLAS
State	:	TX
Zip	:	75214-3634
Country	:	US
Telephone Number	:	214-732-6121
Fax Number	:	214-827-4974

Provider Business Practice Location Address
First Line	:	6130 RICHMOND AVE
Second Line	:
City	:	DALLAS
State	:	TX
Zip	:	75214-3634
Country	:	US
Telephone Number	:	214-732-6121
Fax Number	:	214-827-4974

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

Provider Enumeration Date	:	11/16/2006
Last Update Date	:	07/08/2007

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