MEDICARE: MR. ALEX GUEVARA III LPC

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	101Y00000X	Counselor	75016	TX

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	348806	OTHER	TX	LPC CONTROL NUMBER

General Provider Information

NPI Number	:	1255986832
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. ALEX GUEVARA III LPC

Provider Business Mailing Address
First Line	:	1217 GRAND AVE
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76164-9041
Country	:	US
Telephone Number	:	817-618-0513
Fax Number	:	817-549-0095

Provider Business Practice Location Address
First Line	:	1217 GRAND AVE
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76164-9041
Country	:	US
Telephone Number	:	817-618-0513
Fax Number	:	817-549-0095

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

Provider Enumeration Date	:	08/09/2019
Last Update Date	:	10/05/2021

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