Provider Demographics
NPI:1013410836
Name:FANTOZZI, MEGAN LEE
Entity Type:Individual
Prefix:
First Name:MEGAN
Middle Name:LEE
Last Name:FANTOZZI
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5515 138TH PL SE
Mailing Address - Street 2:
Mailing Address - City:EVERETT
Mailing Address - State:WA
Mailing Address - Zip Code:98208-9450
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:14803 15TH AVE NE
Practice Address - Street 2:
Practice Address - City:SHORELINE
Practice Address - State:WA
Practice Address - Zip Code:98155-7110
Practice Address - Country:US
Practice Address - Phone:206-362-7282
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-03-18
Last Update Date:2018-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health