MEDICARE: COWTOWN CHRISTIAN COUNSELING PLLC

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	261QM0801X	Mental Health Clinic/Center (Including Community Mental Health Center)

General Provider Information

NPI Number	:	1760064067
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	COWTOWN CHRISTIAN COUNSELING PLLC

Provider Business Mailing Address
First Line	:	5589 RED CARDINAL LN
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76114-3620
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1751 RIVER RUN STE 242
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76107-6645
Country	:	US
Telephone Number	:	682-438-7154
Fax Number	:

Authorized Official
Title or Position	:	THERAPIST
Name	:	JOEL PETERSON
Credential	:	LPC
Telephone Number	:	682-438-7154

Provider Enumeration Date	:	04/26/2021
Last Update Date	:	04/26/2021

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