MEDICARE: DAWN MICHELLE ANZUALDA 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	101YP2500X	Professional Counselor	63545	TX

General Provider Information

NPI Number	:	1417254319
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DAWN MICHELLE ANZUALDA LPC

Provider Business Mailing Address
First Line	:	4501 STEPPING STONE DR
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76123-1871
Country	:	US
Telephone Number	:	817-637-9101
Fax Number	:

Provider Business Practice Location Address
First Line	:	3901 AIRPORT FWY
Second Line	:	SUITE 230
City	:	BEDFORD
State	:	TX
Zip	:	76021-6117
Country	:	US
Telephone Number	:	817-354-5200
Fax Number	:	817-354-5201

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

Provider Enumeration Date	:	02/12/2011
Last Update Date	:	02/12/2011

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