MEDICARE: DR. THOMAS KEVIN BURDENSKI JR. LIC. PSYCHOLOGIST

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	33118	TX
2	103TC1900X	Counseling Psychologist	33118	TX

General Provider Information

NPI Number	:	1497939318
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. THOMAS KEVIN BURDENSKI JR. LIC. PSYCHOLOGIST

Provider Business Mailing Address
First Line	:	1532 VERNON CASTLE AVE
Second Line	:
City	:	BENBROOK
State	:	TX
Zip	:	76126-4291
Country	:	US
Telephone Number	:	817-390-0453
Fax Number	:	817-732-7339

Provider Business Practice Location Address
First Line	:	6777 CAMP BOWIE BLVD
Second Line	:	SUITE 338
City	:	FORT WORTH
State	:	TX
Zip	:	76116-7155
Country	:	US
Telephone Number	:	817-390-0453
Fax Number	:	817-732-7339

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

Provider Enumeration Date	:	12/27/2007
Last Update Date	:	06/21/2024

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