MEDICARE: MR. ROBERT E BONTRAGER LSCSW

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	LSCSW 1090	KS

General Provider Information

NPI Number	:	1447200092
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. ROBERT E BONTRAGER LSCSW

Provider Business Mailing Address
First Line	:	1145 E KANSAS PLZ
Second Line	:
City	:	GARDEN CITY
State	:	KS
Zip	:	67846-5870
Country	:	US
Telephone Number	:	620-275-0625
Fax Number	:	620-275-7908

Provider Business Practice Location Address
First Line	:	1145 E KANSAS PLZ
Second Line	:
City	:	GARDEN CITY
State	:	KS
Zip	:	67846-5870
Country	:	US
Telephone Number	:	620-275-0625
Fax Number	:	620-275-7908

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

Provider Enumeration Date	:	05/12/2006
Last Update Date	:	07/08/2007

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