MEDICARE: DR. CARLOS MIGUEL LOREDO PH.D.

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	103T00000X	Psychologist	2-1637	TX

General Provider Information

NPI Number	:	1104978113
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. CARLOS MIGUEL LOREDO PH.D.

Provider Business Mailing Address
First Line	:	2111 MONTCLAIRE ST
Second Line	:
City	:	AUSTIN
State	:	TX
Zip	:	78704-3909
Country	:	US
Telephone Number	:	512-443-0190
Fax Number	:	512-326-4818

Provider Business Practice Location Address
First Line	:	2111 MONTCLAIRE ST
Second Line	:
City	:	AUSTIN
State	:	TX
Zip	:	78704-3909
Country	:	US
Telephone Number	:	512-443-0190
Fax Number	:	512-326-4818

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

Provider Enumeration Date	:	01/18/2007
Last Update Date	:	07/08/2007

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