Provider Demographics
NPI:1225892060
Name:FONTENOT, GRETA M
Entity Type:Individual
Prefix:
First Name:GRETA
Middle Name:M
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 1:4805 SUMMA CT
Mailing Address - Street 2:
Mailing Address - City:BATON ROUGE
Mailing Address - State:LA
Mailing Address - Zip Code:70809-3714
Mailing Address - Country:US
Mailing Address - Phone:337-580-6898
Mailing Address - Fax:
Practice Address - Street 1:7932 SUMMA AVE STE B2
Practice Address - Street 2:
Practice Address - City:BATON ROUGE
Practice Address - State:LA
Practice Address - Zip Code:70809-3736
Practice Address - Country:US
Practice Address - Phone:225-349-7171
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-02-12
Last Update Date:2024-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA012170280106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician