Provider Demographics
NPI:1588212757
Name:FORTNER, RAYMOND SCOTT (MFT)
Entity Type:Individual
Prefix:
First Name:RAYMOND
Middle Name:SCOTT
Last Name:FORTNER
Suffix:
Gender:M
Credentials:MFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:91 W NEAL ST
Mailing Address - Street 2:
Mailing Address - City:PLEASANTON
Mailing Address - State:CA
Mailing Address - Zip Code:94566-6635
Mailing Address - Country:US
Mailing Address - Phone:925-462-4224
Mailing Address - Fax:925-455-1360
Practice Address - Street 1:91 W NEAL ST
Practice Address - Street 2:
Practice Address - City:PLEASANTON
Practice Address - State:CA
Practice Address - Zip Code:94566-6635
Practice Address - Country:US
Practice Address - Phone:925-462-4224
Practice Address - Fax:925-455-1360
Is Sole Proprietor?:Yes
Enumeration Date:2019-08-30
Last Update Date:2019-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFT29516101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health