MEDICARE: MS. DOROTHY G ST JOHN 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	1041C0700X	Clinical Social Worker	LCSW 1766	TX

General Provider Information

NPI Number	:	1558574665
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. DOROTHY G ST JOHN LCSW

Provider Business Mailing Address
First Line	:	3808 WEYBURN DR
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76109-5218
Country	:	US
Telephone Number	:	817-926-7942
Fax Number	:	817-926-2656

Provider Business Practice Location Address
First Line	:	4200 S HULEN ST STE 682
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76109-7905
Country	:	US
Telephone Number	:	817-569-9514
Fax Number	:	817-926-2656

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

Provider Enumeration Date	:	05/07/2007
Last Update Date	:	07/08/2007

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