Provider Demographics
NPI:1558059667
Name:FONTANEZ, ANDRE ANTHONY
Entity Type:Individual
Prefix:
First Name:ANDRE
Middle Name:ANTHONY
Last Name:FONTANEZ
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:500 BEECH ST
Mailing Address - Street 2:
Mailing Address - City:HOLYOKE
Mailing Address - State:MA
Mailing Address - Zip Code:01040-2202
Mailing Address - Country:US
Mailing Address - Phone:441-353-4203
Mailing Address - Fax:
Practice Address - Street 1:500 BEECH ST
Practice Address - Street 2:
Practice Address - City:HOLYOKE
Practice Address - State:MA
Practice Address - Zip Code:01040-2202
Practice Address - Country:US
Practice Address - Phone:441-353-4203
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-04-26
Last Update Date:2023-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker