Provider Demographics
NPI:1639213861
Name:FONTANEZ, IVETTE I (PSYCHOLOGIST)
Entity Type:Individual
Prefix:MISS
First Name:IVETTE
Middle Name:
Last Name:FONTANEZ
Suffix:I
Gender:F
Credentials:PSYCHOLOGIST
Other - Prefix:MISS
Other - First Name:IVETTE
Other - Middle Name:
Other - Last Name:FONTANEZ
Other - Suffix:I
Other - Last Name Type:Professional Name
Other - Credentials:PSYCHOLOGIST
Mailing Address - Street 1:AA2 AVE TEJAS
Mailing Address - Street 2:CORREO VILLA PMB 170
Mailing Address - City:HUMACAO
Mailing Address - State:PR
Mailing Address - Zip Code:00791-4351
Mailing Address - Country:US
Mailing Address - Phone:787-340-7493
Mailing Address - Fax:
Practice Address - Street 1:19 CALLE DUFRESNE E
Practice Address - Street 2:SUITE 1
Practice Address - City:HUMACAO
Practice Address - State:PR
Practice Address - Zip Code:00791-3605
Practice Address - Country:US
Practice Address - Phone:787-340-7493
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR2462103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist