MEDICARE: STACEY LYNN LEWIS 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	40629	TX

General Provider Information

NPI Number	:	1154648236
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	STACEY LYNN LEWIS LCSW

Provider Business Mailing Address
First Line	:	3131 SANGUINET ST
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76107-5336
Country	:	US
Telephone Number	:	817-255-2655
Fax Number	:	817-255-2657

Provider Business Practice Location Address
First Line	:	3800 HULEN ST STE 295
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76107-7276
Country	:	US
Telephone Number	:	817-255-2566
Fax Number	:	817-255-2657

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

Provider Enumeration Date	:	04/28/2010
Last Update Date	:	04/28/2010

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