MEDICARE: TEQUILA LECHAE JOHNSON LMSW

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	104100000X	Social Worker	61888	TX

General Provider Information

NPI Number	:	1215421755
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TEQUILA LECHAE JOHNSON LMSW

Provider Business Mailing Address
First Line	:	5930 SILTSTONE LN APT 723
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76137-8008
Country	:	US
Telephone Number	:	214-218-8784
Fax Number	:

Provider Business Practice Location Address
First Line	:	3509 HULEN ST STE 107
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76107-6800
Country	:	US
Telephone Number	:	214-218-8784
Fax Number	:

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

Provider Enumeration Date	:	06/19/2018
Last Update Date	:	06/19/2018

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