Provider Demographics
NPI:1093186900
Name:FONTAINE, SHIRLEY
Entity Type:Individual
Prefix:
First Name:SHIRLEY
Middle Name:
Last Name:FONTAINE
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 1:441 MILFORD ST
Mailing Address - Street 2:
Mailing Address - City:BURLINGTON
Mailing Address - State:CT
Mailing Address - Zip Code:06013-2212
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:441 MILFORD ST
Practice Address - Street 2:
Practice Address - City:BURLINGTON
Practice Address - State:CT
Practice Address - Zip Code:06013-2212
Practice Address - Country:US
Practice Address - Phone:860-997-4019
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-10-19
Last Update Date:2015-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT001558225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant