MEDICARE: MR. ROGER GRAPE 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	104100000X	Social Worker	25323	TX
2	1041C0700X	Clinical Social Worker	25323	TX

General Provider Information

NPI Number	:	1427319607
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. ROGER GRAPE LCSW

Provider Business Mailing Address
First Line	:	6449 NORWAY RD
Second Line	:
City	:	DALLAS
State	:	TX
Zip	:	75230-5146
Country	:	US
Telephone Number	:	214-502-7084
Fax Number	:

Provider Business Practice Location Address
First Line	:	6449 NORWAY RD
Second Line	:
City	:	DALLAS
State	:	TX
Zip	:	75230-5146
Country	:	US
Telephone Number	:	214-502-7084
Fax Number	:

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

Provider Enumeration Date	:	06/04/2012
Last Update Date	:	06/04/2012

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