MEDICARE: HEATHER REBECCA PANTALONE LICSW

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	LICSW126773	MA
2	103TC0700X	Clinical Psychologist	40905	TX
3	1041C0700X	Clinical Social Worker	63951	TX
4	1041C0700X	Clinical Social Worker	LCSW-5305	HI

General Provider Information

NPI Number	:	1891211066
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	HEATHER REBECCA PANTALONE LICSW

Provider Business Mailing Address
First Line	:	PO BOX 507
Second Line	:
City	:	NOLANVILLE
State	:	TX
Zip	:	76559-0507
Country	:	US
Telephone Number	:	254-415-8466
Fax Number	:

Provider Business Practice Location Address
First Line	:	3309 VINEYARD TRL
Second Line	:
City	:	HARKER HEIGHTS
State	:	TX
Zip	:	76548-8847
Country	:	US
Telephone Number	:	555-555-5555
Fax Number	:

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

Provider Enumeration Date	:	08/18/2017
Last Update Date	:	03/27/2026

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Directions to “ HEATHER REBECCA PANTALONE LICSW” Practice Location

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