Provider Demographics
NPI:1114709540
Name:FONTENOT, CARLEY R
Entity Type:Individual
Prefix:
First Name:CARLEY
Middle Name:R
Last Name:FONTENOT
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 1:4201 N I 10 SERVICE RD W
Mailing Address - Street 2:
Mailing Address - City:METAIRIE
Mailing Address - State:LA
Mailing Address - Zip Code:70006-6713
Mailing Address - Country:US
Mailing Address - Phone:504-475-5303
Mailing Address - Fax:
Practice Address - Street 1:12470 HEBERT RD
Practice Address - Street 2:
Practice Address - City:GONZALES
Practice Address - State:LA
Practice Address - Zip Code:70737-7656
Practice Address - Country:US
Practice Address - Phone:225-290-8023
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-10-19
Last Update Date:2023-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician