MEDICARE: GLYNIS PARK MS

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

General Provider Information

NPI Number	:	1275016552
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	GLYNIS PARK MS

Provider Business Mailing Address
First Line	:	201 N RUPERT ST STE 133
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76107-1465
Country	:	US
Telephone Number	:	817-516-9100
Fax Number	:

Provider Business Practice Location Address
First Line	:	201 N RUPERT ST STE 133
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76107-1465
Country	:	US
Telephone Number	:	817-516-9100
Fax Number	:

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

Provider Enumeration Date	:	09/12/2018
Last Update Date	:	04/14/2026

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Directions to “ GLYNIS PARK MS” Practice Location

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