Provider Demographics
NPI:1376115733
Name:FORTUNE, IRIS EMILY (LCSWC)
Entity Type:Individual
Prefix:
First Name:IRIS
Middle Name:EMILY
Last Name:FORTUNE
Suffix:
Gender:F
Credentials:LCSWC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5900 YORK RD STE 201
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21212-3097
Mailing Address - Country:US
Mailing Address - Phone:443-563-1021
Mailing Address - Fax:
Practice Address - Street 1:5900 YORK RD STE 201
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21212-3097
Practice Address - Country:US
Practice Address - Phone:443-563-1021
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-07-14
Last Update Date:2021-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDLCA142101YA0400X
MD040781041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)