Provider Demographics
NPI:1528214889
Name:FONTENEAU, DANA PUTNAM (MM, MA)
Entity Type:Individual
Prefix:MS
First Name:DANA
Middle Name:PUTNAM
Last Name:FONTENEAU
Suffix:
Gender:F
Credentials:MM, MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:776 GRIZZLY PEAK BLVD
Mailing Address - Street 2:
Mailing Address - City:BERKELEY
Mailing Address - State:CA
Mailing Address - Zip Code:94708-1337
Mailing Address - Country:US
Mailing Address - Phone:510-847-3884
Mailing Address - Fax:
Practice Address - Street 1:315 SANCHEZ ST
Practice Address - Street 2:
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94114-1615
Practice Address - Country:US
Practice Address - Phone:415-820-1691
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-08-18
Last Update Date:2008-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAIMF 54561101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health