MEDICARE: LATHA IYENGAR LCSW, ACP

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	S11144	TX

General Provider Information

NPI Number	:	1750493458
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LATHA IYENGAR LCSW, ACP

Provider Business Mailing Address
First Line	:	8604 DEL MESA LN
Second Line	:
City	:	AUSTIN
State	:	TX
Zip	:	78759-6837
Country	:	US
Telephone Number	:	512-250-1441
Fax Number	:	512-250-2110

Provider Business Practice Location Address
First Line	:	12885 N HIGHWAY 183
Second Line	:	SUITE # 209-A
City	:	AUSTIN
State	:	TX
Zip	:	78750-3220
Country	:	US
Telephone Number	:	512-250-1441
Fax Number	:	512-250-2110

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

Provider Enumeration Date	:	08/31/2006
Last Update Date	:	07/08/2007

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