MEDICARE: MS. CARLA YVONNE STOREY 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	34196	TX

General Provider Information

NPI Number	:	1225177512
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. CARLA YVONNE STOREY LCSW

Provider Business Mailing Address
First Line	:	5317 GORDON AVE
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76115-4112
Country	:	US
Telephone Number	:	817-501-2033
Fax Number	:

Provider Business Practice Location Address
First Line	:	1424 SUMMIT AVE
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76102-5912
Country	:	US
Telephone Number	:	817-335-4673
Fax Number	:

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

Provider Enumeration Date	:	02/05/2007
Last Update Date	:	07/08/2007

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