Healthcare Provider Details

I. General information

NPI: 1578571964
Provider Name (Legal Business Name): JOHN LAUTERBACH LCSW
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/03/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4401 BUSINESS PARK BLVD SUITE 24
ANCHORAGE AK
99503-7117
US

IV. Provider business mailing address

PO BOX 243461
ANCHORAGE AK
99524-3461
US

V. Phone/Fax

Practice location:
  • Phone: 907-242-3801
  • Fax: 907-646-9784
Mailing address:
  • Phone: 907-242-3801
  • Fax: 907-646-9784

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number178
License Number StateAK
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number989425
License Number StateCO

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: