MEDICARE: MR. BRUCE NEUSTADTER MFT

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	106H00000X	Marriage & Family Therapist	MV17498	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MV17498	OTHER	CA	STATE LICENSE

General Provider Information

NPI Number	:	1326106832
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. BRUCE NEUSTADTER MFT

Provider Business Mailing Address
First Line	:	710 RIVER ST
Second Line	:
City	:	SANTA CRUZ
State	:	CA
Zip	:	95060-2748
Country	:	US
Telephone Number	:	831-423-4566
Fax Number	:

Provider Business Practice Location Address
First Line	:	710 RIVER ST
Second Line	:
City	:	SANTA CRUZ
State	:	CA
Zip	:	95060-2748
Country	:	US
Telephone Number	:	831-423-4566
Fax Number	:

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

Provider Enumeration Date	:	12/05/2006
Last Update Date	:	07/08/2007

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