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General NPI Number Information
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NPI Number | 1053600155
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Entity Type | Organization
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Legal Business Name | FORTITUDE PSYCHOTHERAPY
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Dates
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Enumeration Date | 03/30/2011
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Last Update Date | 03/30/2011
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Provider Practice Location Address
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Address Line | 3903 WISEMAN BLVD STE #211
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City | SAN ANTONIO
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State | TX
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Zip | 78251-4401
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Country | US
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Telephone | 210-381-6593
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Fax |
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Provider Business Mailing Address
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Address Line | 6130 BRISCOE LEAF
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City | SAN ANTONIO
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State | TX
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Zip | 78253-5524
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | MANAGER
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Name | MICHAEL GAMBUTI
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Credential | LPC, NCC
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Telephone | 210-381-6593
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101Y00000X
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Taxonomy Name | Counselor
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License Number | 60992
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License Number State | TX
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