Provider Demographics
NPI:1609816636
Name:FORTUNATA, BLAISE (PSYCHOLOGIST)
Entity Type:Individual
Prefix:
First Name:BLAISE
Middle Name:
Last Name:FORTUNATA
Suffix:
Gender:F
Credentials:PSYCHOLOGIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:460 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:HYANNIS
Mailing Address - State:MA
Mailing Address - Zip Code:02601-3855
Mailing Address - Country:US
Mailing Address - Phone:508-790-3360
Mailing Address - Fax:508-790-3378
Practice Address - Street 1:460 W MAIN ST
Practice Address - Street 2:
Practice Address - City:HYANNIS
Practice Address - State:MA
Practice Address - Zip Code:02601-3855
Practice Address - Country:US
Practice Address - Phone:508-790-3360
Practice Address - Fax:508-790-3378
Is Sole Proprietor?:No
Enumeration Date:2006-06-07
Last Update Date:2021-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA8563103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAW51531Medicare ID - Type Unspecified