Provider Demographics
NPI:1659039584
Name:FONTAINE, DAMARIS
Entity Type:Individual
Prefix:
First Name:DAMARIS
Middle Name:
Last Name:FONTAINE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:72800 30TH AVE
Mailing Address - Street 2:
Mailing Address - City:THOUSAND PALMS
Mailing Address - State:CA
Mailing Address - Zip Code:92276-2955
Mailing Address - Country:US
Mailing Address - Phone:951-234-1270
Mailing Address - Fax:
Practice Address - Street 1:473 E. CARNEGIE DRIVE
Practice Address - Street 2:SUITE 200
Practice Address - City:SAN BERNARDINO
Practice Address - State:CA
Practice Address - Zip Code:92408
Practice Address - Country:US
Practice Address - Phone:909-277-6090
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-12-08
Last Update Date:2021-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst