MEDICARE: DORTHA WEBB LCDC

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	101YA0400X	Addiction (Substance Use Disorder) Counselor	11584	TX

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	11584	OTHER	TX	TEXAS DEPT OF STATE HEALTH SERVICES

General Provider Information

NPI Number	:	1578076089
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DORTHA WEBB LCDC

Provider Business Mailing Address
First Line	:	3001A W 5TH ST
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76107-2206
Country	:	US
Telephone Number	:	817-338-0311
Fax Number	:	817-332-9075

Provider Business Practice Location Address
First Line	:	3001A W 5TH ST
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76107-2206
Country	:	US
Telephone Number	:	817-338-0311
Fax Number	:	817-332-9075

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

Provider Enumeration Date	:	11/07/2017
Last Update Date	:	11/07/2017

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