MEDICARE: MR. JAMES EDWARD BALLENGER 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	23853	TX
2	171M00000X	Case Manager/Care Coordinator	23853	TX

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1730202466
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. JAMES EDWARD BALLENGER LCSW

Provider Business Mailing Address
First Line	:	PO BOX 331581
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76163-1581
Country	:	US
Telephone Number	:	817-975-8015
Fax Number	:	817-361-9958

Provider Business Practice Location Address
First Line	:	4200 SOUTH FWY STE 2325
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76115-1400
Country	:	US
Telephone Number	:	817-975-8015
Fax Number	:	817-361-9958

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

Provider Enumeration Date	:	04/09/2007
Last Update Date	:	06/13/2012

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