Healthcare Provider Details

I. General information

NPI: 1932825031
Provider Name (Legal Business Name): NICK PANTUSO LPC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/19/2022
Last Update Date: 10/19/2022
Certification Date: 10/19/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8310 EWING HALSELL DR
SAN ANTONIO TX
78229-3715
US

IV. Provider business mailing address

8411 SPICEWOOD BND
SAN ANTONIO TX
78255-2240
US

V. Phone/Fax

Practice location:
  • Phone: 210-616-0885
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number68973
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: