Provider Demographics
NPI:1598121188
Name:FORTIN, ANGELIQUE ALICIA (LCMHC)
Entity Type:Individual
Prefix:
First Name:ANGELIQUE
Middle Name:ALICIA
Last Name:FORTIN
Suffix:
Gender:F
Credentials:LCMHC
Other - Prefix:
Other - First Name:ANGIE
Other - Middle Name:
Other - Last Name:LONG/ROBERTS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MS LCMHC
Mailing Address - Street 1:101 COTTAGE ST STE 5B
Mailing Address - Street 2:
Mailing Address - City:LITTLETON
Mailing Address - State:NH
Mailing Address - Zip Code:03561-4218
Mailing Address - Country:US
Mailing Address - Phone:603-991-1304
Mailing Address - Fax:
Practice Address - Street 1:101 COTTAGE ST STE 5B
Practice Address - Street 2:
Practice Address - City:LITTLETON
Practice Address - State:NH
Practice Address - Zip Code:03561-4218
Practice Address - Country:US
Practice Address - Phone:603-991-1304
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-01-12
Last Update Date:2021-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH2035101YM0800X, 101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health