Provider Demographics
NPI:1639884331
Name:FONTENOT, ROY BENNETT
Entity Type:Individual
Prefix:
First Name:ROY
Middle Name:BENNETT
Last Name:FONTENOT
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2704 BULLIS AVE
Mailing Address - Street 2:
Mailing Address - City:GULFPORT
Mailing Address - State:MS
Mailing Address - Zip Code:39501-5231
Mailing Address - Country:US
Mailing Address - Phone:228-223-5250
Mailing Address - Fax:
Practice Address - Street 1:283 DEBUYS RD
Practice Address - Street 2:
Practice Address - City:GULFPORT
Practice Address - State:MS
Practice Address - Zip Code:39507-2800
Practice Address - Country:US
Practice Address - Phone:228-731-3500
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-01-17
Last Update Date:2023-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician