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605 Shady Ln N Keller TX 76248-2645 | |
| (817) 522-6622 | |
| (817) 379-1933 |
| Full Name | |
|---|---|
| Speciality | Social Worker |
| Location | 605 Shady Ln N, Keller, Texas |
| Authorized Official Name and Position | Aileen Devereaux (OWNER) |
| Authorized Official Contact | 8175226622 |
| Accepts Medicare Insurance | Yes. This clinic participates in medicare program and accept medicare insurance. |
| Mailing Address | Practice Location Address |
|---|---|
605 Shady Ln N Keller TX 76248-2645 Ph: (817) 522-6622 | 605 Shady Ln N Keller TX 76248-2645 Ph: (817) 522-6622 |
| NPI Number | 1609303791 |
|---|---|
| Provider Enumeration Date | 05/19/2017 |
| Last Update Date | 02/02/2021 |
| Certification Date | 02/02/2021 |
| Medicare PECOS PAC ID | 1759650070 |
|---|---|
| Medicare Enrollment ID | O20170629002575 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1609303791 | NPI | - | NPPES |
| 2879785-03 | Medicaid | TX | |
| 2879785-02 | Medicaid | TX | |
| 400299001 | Medicaid | TX | |
| 2879785-04 | Medicaid | TX |
| Taxonomy | Type | License (State) | Status |
|---|---|---|---|
| 1041C0700X | Social Worker - Clinical | 41287 (Texas) | Primary |
| Provider Name | Aileen Carole Wainwright |
|---|---|
| Provider Type | Practitioner - Clinical Social Worker |
| Provider Identifiers | NPI Number: 1780831396 PECOS PAC ID: 1951622281 Enrollment ID: I20150611001392 |
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