MEDICARE: SRP BEHAVIORAL HOSPITAL OF FORT WORTH LLC

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	283Q00000X	Psychiatric Hospital	100246	TX

General Provider Information

NPI Number	:	1447672910
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SRP BEHAVIORAL HOSPITAL OF FORT WORTH LLC

Provider Business Mailing Address
First Line	:	8343 DOUGLAS AVE STE 350
Second Line	:
City	:	DALLAS
State	:	TX
Zip	:	75225-5887
Country	:	US
Telephone Number	:	817-361-1991
Fax Number	:	817-361-1993

Provider Business Practice Location Address
First Line	:	6200 OVERTON RIDGE BLVD
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76132-0000
Country	:	US
Telephone Number	:	817-361-1991
Fax Number	:	817-361-1993

Authorized Official
Title or Position	:	DELEGATED/AUTHORIZED OFFICIAL
Name	:	BARBARA SHOUSE
Credential	:
Telephone Number	:	502-680-2115

Provider Enumeration Date	:	01/17/2014
Last Update Date	:	04/08/2020

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