MEDICARE: SARAH JANE BENTZ LPC-INTERN

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	65828	TX

General Provider Information

NPI Number	:	1508147299
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SARAH JANE BENTZ LPC-INTERN

Provider Business Mailing Address
First Line	:	3625 WESTERN CENTER BLVD STE 211
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76137-1936
Country	:	US
Telephone Number	:	817-232-9400
Fax Number	:	817-232-9403

Provider Business Practice Location Address
First Line	:	3625 WESTERN CENTER BLVD STE 211
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76137-1936
Country	:	US
Telephone Number	:	817-232-9400
Fax Number	:	817-232-9403

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

Provider Enumeration Date	:	09/08/2011
Last Update Date	:	09/08/2011

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