MEDICARE: CHAVA SHIRA ROUSCH-CARLISLE LCSW, APHSW-C

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	101YP2500X	Professional Counselor
2	1041C0700X	Clinical Social Worker	63773	TX

General Provider Information

NPI Number	:	1184378143
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CHAVA SHIRA ROUSCH-CARLISLE LCSW, APHSW-C

Provider Business Mailing Address
First Line	:	1418 W PIPELINE RD # 103
Second Line	:
City	:	HURST
State	:	TX
Zip	:	76053-4629
Country	:	US
Telephone Number	:	817-692-6917
Fax Number	:

Provider Business Practice Location Address
First Line	:	3210 W PARK ROW DR
Second Line	:
City	:	PANTEGO
State	:	TX
Zip	:	76013-3136
Country	:	US
Telephone Number	:	817-692-6917
Fax Number	:

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

Provider Enumeration Date	:	02/08/2022
Last Update Date	:	01/23/2024

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