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NPI Code Detail

MEDICARE: LAKESHA STIDUM

MEDICARE: LAKESHA STIDUM
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
11041C0700XClinical Social Worker

General Provider Information

NPI Number : 1891107660
Entity Type Code : Individual
Provider Name (Legal Business Name) : LAKESHA STIDUM
Provider Business Mailing Address
First Line : 3964 WATERCOURSE DR APT 1458
Second Line :
City : FORT WORTH
State : TX
Zip : 76109-2091
Country : US
Telephone Number : 870-270-7975
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 : 870-270-7975
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 05/28/2014
Last Update Date : 11/11/2022

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Directions to “ LAKESHA STIDUM ” Practice Location

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