MEDICARE: MRS. AVA PROFOTA 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	36093	TX

General Provider Information

NPI Number	:	1760530489
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. AVA PROFOTA LCSW

Provider Business Mailing Address
First Line	:	2000 NORTH LOOP W
Second Line	:	SUITE 200
City	:	HOUSTON
State	:	TX
Zip	:	77018-8124
Country	:	US
Telephone Number	:	713-868-2908
Fax Number	:	713-864-2395

Provider Business Practice Location Address
First Line	:	2000 NORTH LOOP W
Second Line	:	SUITE 200
City	:	HOUSTON
State	:	TX
Zip	:	77018-8124
Country	:	US
Telephone Number	:	713-868-2908
Fax Number	:	713-864-2395

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

Provider Enumeration Date	:	01/08/2007
Last Update Date	:	03/14/2008

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