MEDICARE: DR. CAROL STALCUP PH.D.

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	103T00000X	Psychologist	2-2451	TX

General Provider Information

NPI Number	:	1396112322
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. CAROL STALCUP PH.D.

Provider Business Mailing Address
First Line	:	6421 CAMP BOWIE BLVD
Second Line	:	SUITE 306
City	:	FORT WORTH
State	:	TX
Zip	:	76116-5401
Country	:	US
Telephone Number	:	817-732-7748
Fax Number	:

Provider Business Practice Location Address
First Line	:	6421 CAMP BOWIE BLVD
Second Line	:	SUITE 306
City	:	FORT WORTH
State	:	TX
Zip	:	76116-5401
Country	:	US
Telephone Number	:	817-732-7748
Fax Number	:

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

Provider Enumeration Date	:	08/25/2015
Last Update Date	:	08/25/2015

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