Basic Information
| Provider Information | |||||||||
| NPI: | 1134519234 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MOSHARAF | ||||||||
| FirstName: | DAMARIS | ||||||||
| MiddleName: | SARAHY | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | LCSW | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | LOPEZ-MOSHARAF | ||||||||
| OtherFirstName: | DAMARIS | ||||||||
| OtherMiddleName: | SARAY | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | LCSW | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 2106 N MAIN ST | ||||||||
| Address2: | |||||||||
| City: | FORT WORTH | ||||||||
| State: | TX | ||||||||
| PostalCode: | 761648511 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8176254254 | ||||||||
| FaxNumber: | 5122915657 | ||||||||
| Practice Location | |||||||||
| Address1: | 2106 N MAIN ST | ||||||||
| Address2: | |||||||||
| City: | FORT WORTH | ||||||||
| State: | TX | ||||||||
| PostalCode: | 761648511 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8176254254 | ||||||||
| FaxNumber: | 5122915657 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/27/2015 | ||||||||
| LastUpdateDate: | 01/27/2015 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialNameSuffix: | |||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | 56168 | TX | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
ID Information
| ID | Type | State | Issuer | Description | 56168 | 01 | TX | LICENSE | OTHER |