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NPI Code Detail

MEDICARE: MS. SHAVON DONASINA CORMICK LMSW

MEDICARE: MS. SHAVON DONASINA CORMICK LMSW
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
1104100000XSocial Worker52367TX

General Provider Information

NPI Number : 1821431073
Entity Type Code : Individual
Provider Name (Legal Business Name) : MS. SHAVON DONASINA CORMICK LMSW
Provider Business Mailing Address
First Line : 101 NEW YORK AVE
Second Line :
City : FORT WORTH
State : TX
Zip : 76104-1558
Country : US
Telephone Number : 817-255-7153
Fax Number :
Provider Business Practice Location Address
First Line : 101 NEW YORK AVE
Second Line :
City : FORT WORTH
State : TX
Zip : 76104-1558
Country : US
Telephone Number : 817-255-7153
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 04/08/2013
Last Update Date : 04/08/2013

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