Provider Demographics
NPI:1619696515
Name:FONTENOT, CHARLES R JR (LCDC)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:R
Last Name:FONTENOT
Suffix:JR
Gender:M
Credentials:LCDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 550382
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77255-0382
Mailing Address - Country:US
Mailing Address - Phone:281-546-3740
Mailing Address - Fax:
Practice Address - Street 1:11301 RICHMOND AVE STE K105
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77082-5549
Practice Address - Country:US
Practice Address - Phone:281-293-9600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-08-24
Last Update Date:2022-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX16043101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)