Provider Demographics
NPI:1053600155
Name:FORTITUDE PSYCHOTHERAPY
Entity type:Organization
Organization Name:FORTITUDE PSYCHOTHERAPY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:GAMBUTI
Authorized Official - Suffix:
Authorized Official - Credentials:LPC, NCC
Authorized Official - Phone:210-381-6593
Mailing Address - Street 1:6130 BRISCOE LEAF
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78253-5524
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3903 WISEMAN BLVD
Practice Address - Street 2:STE #211
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78251-4401
Practice Address - Country:US
Practice Address - Phone:210-381-6593
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-03-30
Last Update Date:2011-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX60992101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselorGroup - Single Specialty