MEDICARE: JOHN HERTENBERGER 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	24064	TX

General Provider Information

NPI Number	:	1245455195
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JOHN HERTENBERGER PH.D.

Provider Business Mailing Address
First Line	:	1823 FORTVIEW RD STE 203
Second Line	:
City	:	AUSTIN
State	:	TX
Zip	:	78704-7663
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1823 FORTVIEW RD STE 203
Second Line	:
City	:	AUSTIN
State	:	TX
Zip	:	78704-7663
Country	:	US
Telephone Number	:	512-499-8674
Fax Number	:

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

Provider Enumeration Date	:	04/16/2007
Last Update Date	:	07/08/2007

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