MEDICARE: RESTORATION COUNSELING & PSYCHOTHERAPY

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	251S00000X	Community/Behavioral Health Agency	61635	TX
2	251S00000X	Community/Behavioral Health Agency	19974	TX

General Provider Information

NPI Number	:	1619126497
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	RESTORATION COUNSELING & PSYCHOTHERAPY

Provider Business Mailing Address
First Line	:	2804 SE LOOP 820
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76140-1012
Country	:	US
Telephone Number	:	817-293-1555
Fax Number	:	817-293-1566

Provider Business Practice Location Address
First Line	:	2804 SE LOOP 820
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76140-1012
Country	:	US
Telephone Number	:	817-293-1555
Fax Number	:	817-293-1566

Authorized Official
Title or Position	:	OWNER
Name	:	MR. DAVID WAYNE SUTTON
Credential	:	LPC
Telephone Number	:	817-293-1555

Provider Enumeration Date	:	09/16/2008
Last Update Date	:	09/16/2008

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