Provider Demographics
NPI:1518362490
Name:FONTEBOA, MIRTA V (CSW - CDP)
Entity Type:Individual
Prefix:MS
First Name:MIRTA
Middle Name:V
Last Name:FONTEBOA
Suffix:
Gender:F
Credentials:CSW - CDP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:324-55TH ST
Mailing Address - Street 2:CASA MANITO AMDCC
Mailing Address - City:WEST NEW YORK
Mailing Address - State:NJ
Mailing Address - Zip Code:07093
Mailing Address - Country:US
Mailing Address - Phone:201-223-6800
Mailing Address - Fax:201-223-6885
Practice Address - Street 1:324-55TH ST
Practice Address - Street 2:CASA MANITO AMDCC
Practice Address - City:WEST NEW YORK
Practice Address - State:NJ
Practice Address - Zip Code:07093
Practice Address - Country:US
Practice Address - Phone:201-223-6800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-11-04
Last Update Date:2014-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker