MEDICARE: HOME OF LIFE JOURNEY

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	103K00000X	Behavior Analyst

General Provider Information

NPI Number	:	1871852970
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	HOME OF LIFE JOURNEY

Provider Business Mailing Address
First Line	:	4228 HARDEMAN ST
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76119-3870
Country	:	US
Telephone Number	:	817-769-0379
Fax Number	:

Provider Business Practice Location Address
First Line	:	4228 HARDEMAN ST
Second Line	:
City	:	FT WORTH
State	:	TX
Zip	:	76119-3870
Country	:	US
Telephone Number	:	817-769-0379
Fax Number	:

Authorized Official
Title or Position	:	OWNER/PROGRAM MANAGER
Name	:	MISS MARIAN DENISE WALTERS
Credential	:	MSW
Telephone Number	:	817-769-0379

Provider Enumeration Date	:	05/09/2012
Last Update Date	:	05/09/2012

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Directions to “HOME OF LIFE JOURNEY ” Practice Location

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