MEDICARE: BROOKE NICOLE POWELL LPC

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	101YM0800X	Mental Health Counselor	72602	TX

General Provider Information

NPI Number	:	1932713385
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	BROOKE NICOLE POWELL LPC

Provider Business Mailing Address
First Line	:	1804 GLENMORE AVE
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76102-1509
Country	:	US
Telephone Number	:	817-368-9679
Fax Number	:

Provider Business Practice Location Address
First Line	:	1804 GLENMORE AVE
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76102-1509
Country	:	US
Telephone Number	:	817-368-9679
Fax Number	:

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

Provider Enumeration Date	:	09/03/2020
Last Update Date	:	09/03/2020

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