MEDICARE: JULIET FORTINO MC, LPC, RPT-S

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	LPC-10235	AZ
2	101YM0800X	Mental Health Counselor	LPC-10235	AZ
3	101YP2500X	Professional Counselor	LPC-10235	AZ

General Provider Information

NPI Number	:	1477999498
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JULIET FORTINO MC, LPC, RPT-S

Provider Business Mailing Address
First Line	:	PO BOX 89364
Second Line	:
City	:	TUCSON
State	:	AZ
Zip	:	85752-9364
Country	:	US
Telephone Number	:	520-240-8488
Fax Number	:

Provider Business Practice Location Address
First Line	:	3801 N CAMPBELL AVE STE A
Second Line	:
City	:	TUCSON
State	:	AZ
Zip	:	85719-1448
Country	:	US
Telephone Number	:	520-240-8488
Fax Number	:

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

Provider Enumeration Date	:	05/16/2013
Last Update Date	:	10/15/2013

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