MEDICARE: MR. PETER DOLF PANTHAUER MFT

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	106H00000X	Marriage & Family Therapist	000662	CT

General Provider Information

NPI Number	:	1326708934
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. PETER DOLF PANTHAUER MFT

Provider Business Mailing Address
First Line	:	60 KATONA DR STE 25A
Second Line	:
City	:	FAIRFIELD
State	:	CT
Zip	:	06824-3547
Country	:	US
Telephone Number	:	203-295-5273
Fax Number	:

Provider Business Practice Location Address
First Line	:	60 KATONA DR STE 25A
Second Line	:
City	:	FAIRFIELD
State	:	CT
Zip	:	06824-3547
Country	:	US
Telephone Number	:	203-295-5273
Fax Number	:

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

Provider Enumeration Date	:	12/22/2021
Last Update Date	:	12/22/2021

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