MEDICARE: MRS. MARY THOMPSON

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		TX

General Provider Information

NPI Number	:	1669015590
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. MARY THOMPSON

Provider Business Mailing Address
First Line	:	6009 ED COADY RD
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76134-2502
Country	:	US
Telephone Number	:	817-228-0399
Fax Number	:

Provider Business Practice Location Address
First Line	:	6733 CAMP BOWIE BLVD
Second Line	:
City	:	FT WORTH
State	:	TX
Zip	:	76116-7112
Country	:	US
Telephone Number	:	817-386-9180
Fax Number	:	817-386-9138

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

Provider Enumeration Date	:	10/23/2019
Last Update Date	:	10/23/2019

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Directions to “ MRS. MARY THOMPSON ” Practice Location

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