MEDICARE: DR. HALLIE SHEADE PHD, LPC-S, RPT-S

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	67848	TX

General Provider Information

NPI Number	:	1194149336
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. HALLIE SHEADE PHD, LPC-S, RPT-S

Provider Business Mailing Address
First Line	:	PO BOX 122692
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76121-2692
Country	:	US
Telephone Number	:	682-334-3784
Fax Number	:

Provider Business Practice Location Address
First Line	:	16151 HIGHWAY 377 S
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76126-5544
Country	:	US
Telephone Number	:	682-334-3784
Fax Number	:

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

Provider Enumeration Date	:	02/07/2014
Last Update Date	:	01/13/2022

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