MEDICARE: ANTHONY ALTENBACH LCSW

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	1041C0700X	Clinical Social Worker	LCS 6975	CA

General Provider Information

NPI Number	:	1124224175
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ANTHONY ALTENBACH LCSW

Provider Business Mailing Address
First Line	:	325 W HOSPITALITY LN
Second Line	:	SUITE312
City	:	SAN BERNARDINO
State	:	CA
Zip	:	92408-3243
Country	:	US
Telephone Number	:	909-386-5500
Fax Number	:	909-386-5520

Provider Business Practice Location Address
First Line	:	325 W HOSPITALITY LN
Second Line	:	SUITE312
City	:	SAN BERNARDINO
State	:	CA
Zip	:	92408-3243
Country	:	US
Telephone Number	:	909-386-5500
Fax Number	:	909-386-5520

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

Provider Enumeration Date	:	06/26/2007
Last Update Date	:	07/08/2007

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