MEDICARE: KEAUNNA SHAUNTASIA GAMBLE 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	104385	TX

General Provider Information

NPI Number	:	1326858333
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KEAUNNA SHAUNTASIA GAMBLE LCSW

Provider Business Mailing Address
First Line	:	2204 PARK PLACE AVE STE B
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76110-1234
Country	:	US
Telephone Number	:	682-292-8515
Fax Number	:

Provider Business Practice Location Address
First Line	:	2204 PARK PLACE AVE STE B
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76110-1234
Country	:	US
Telephone Number	:	682-292-8515
Fax Number	:

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

Provider Enumeration Date	:	01/10/2025
Last Update Date	:	02/01/2025

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