MEDICARE: MARY LOVEGREN

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	11914	TX

General Provider Information

NPI Number	:	1588095756
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARY LOVEGREN

Provider Business Mailing Address
First Line	:	4230 LOCKE AVE
Second Line	:
City	:	FT. WORTH
State	:	TX
Zip	:	76107
Country	:	US
Telephone Number	:	817-602-0209
Fax Number	:	817-870-9996

Provider Business Practice Location Address
First Line	:	4230 LOCKE AVE
Second Line	:
City	:	FT. WORTH
State	:	TX
Zip	:	76107
Country	:	US
Telephone Number	:	817-602-0209
Fax Number	:	817-870-9996

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

Provider Enumeration Date	:	12/12/2013
Last Update Date	:	03/28/2017

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Directions to “ MARY LOVEGREN ” Practice Location

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