MEDICARE: LATHA SHRIVATSA

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	51836	TX

General Provider Information

NPI Number	:	1235545500
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LATHA SHRIVATSA

Provider Business Mailing Address
First Line	:	1906 MCCARTNEY CT
Second Line	:
City	:	ARLINGTON
State	:	TX
Zip	:	76012-2030
Country	:	US
Telephone Number	:	817-704-3232
Fax Number	:

Provider Business Practice Location Address
First Line	:	1723 HEMPHILL ST
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76110-1516
Country	:	US
Telephone Number	:	817-927-4040
Fax Number	:

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

Provider Enumeration Date	:	07/08/2014
Last Update Date	:	07/17/2014

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Directions to “ LATHA SHRIVATSA ” Practice Location

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