MEDICARE: FORTITUDE PSYCHOTHERAPY

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	101Y00000X	Counselor	60992	TX

General Provider Information

NPI Number	:	1053600155
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	FORTITUDE PSYCHOTHERAPY

Provider Business Mailing Address
First Line	:	6130 BRISCOE LEAF
Second Line	:
City	:	SAN ANTONIO
State	:	TX
Zip	:	78253-5524
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	3903 WISEMAN BLVD
Second Line	:	STE #211
City	:	SAN ANTONIO
State	:	TX
Zip	:	78251-4401
Country	:	US
Telephone Number	:	210-381-6593
Fax Number	:

Authorized Official
Title or Position	:	MANAGER
Name	:	MICHAEL GAMBUTI
Credential	:	LPC, NCC
Telephone Number	:	210-381-6593

Provider Enumeration Date	:	03/30/2011
Last Update Date	:	03/30/2011

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