Healthcare Provider Details

I. General information

NPI: 1598391773
Provider Name (Legal Business Name): JONATHAN ALTANY
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/19/2020
Last Update Date: 12/05/2023
Certification Date: 12/05/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

310 BENNETT AVE
RAVENNA OH
44266-3211
US

IV. Provider business mailing address

1055 E COLORADO BLVD STE 560
PASADENA CA
91106-2380
US

V. Phone/Fax

Practice location:
  • Phone: 330-839-9966
  • Fax:
Mailing address:
  • Phone: 818-241-6780
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberC.2305572
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: