MEDICARE: FORT BEND COUNSELING AND 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	1041C0700X	Clinical Social Worker	34220	TX
2	1041C0700X	Clinical Social Worker	35247	TX

General Provider Information

NPI Number	:	1740712025
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	FORT BEND COUNSELING AND PSYCHOTHERAPY

Provider Business Mailing Address
First Line	:	4501 CARTWRIGHT RD STE 103
Second Line	:
City	:	MISSOURI CITY
State	:	TX
Zip	:	77459-3537
Country	:	US
Telephone Number	:	713-231-8858
Fax Number	:	281-302-5401

Provider Business Practice Location Address
First Line	:	4501 CARTWRIGHT RD STE 103
Second Line	:
City	:	MISSOURI CITY
State	:	TX
Zip	:	77459-3537
Country	:	US
Telephone Number	:	713-231-8858
Fax Number	:	281-302-5401

Authorized Official
Title or Position	:	PSYCHOTHERAPIST/OWNER
Name	:	MRS. CARMEL HELAINE MATALLANA
Credential	:	LCSW
Telephone Number	:	713-231-8858

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

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