MEDICARE: MICHAEL RAY THRONEBERRY 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	40963	TX

General Provider Information

NPI Number	:	1710496781
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MICHAEL RAY THRONEBERRY LCSW

Provider Business Mailing Address
First Line	:	4620 CLOUDVIEW RD
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76109-3326
Country	:	US
Telephone Number	:	214-415-7093
Fax Number	:

Provider Business Practice Location Address
First Line	:	1814 8TH AVE
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76110-1354
Country	:	US
Telephone Number	:	214-415-7093
Fax Number	:

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

Provider Enumeration Date	:	09/21/2017
Last Update Date	:	09/10/2022

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