MEDICARE: INNER CITY COMMUNITY SERVICES OF TARRANT COUNTY

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	101YP2500X	Professional Counselor

General Provider Information

NPI Number	:	1871896217
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	INNER CITY COMMUNITY SERVICES OF TARRANT COUNTY

Provider Business Mailing Address
First Line	:	4925 RICKEE DR
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76115-3651
Country	:	US
Telephone Number	:	817-607-8184
Fax Number	:	208-888-2476

Provider Business Practice Location Address
First Line	:	4925 RICKEE DR
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76115-3651
Country	:	US
Telephone Number	:	817-607-8184
Fax Number	:	208-888-2476

Authorized Official
Title or Position	:	DIRECTOR
Name	:	MS. RUTH C GREENE
Credential	:
Telephone Number	:	817-607-8184

Provider Enumeration Date	:	12/07/2010
Last Update Date	:	12/07/2010

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