Provider Demographics
NPI:1679503924
Name:FONTAINE, AMANDA L (LMFT)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:L
Last Name:FONTAINE
Suffix:
Gender:F
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:23 NORTH RD STE A25
Mailing Address - Street 2:
Mailing Address - City:PEACE DALE
Mailing Address - State:RI
Mailing Address - Zip Code:02879-2176
Mailing Address - Country:US
Mailing Address - Phone:401-487-7042
Mailing Address - Fax:
Practice Address - Street 1:23 NORTH RD STE A25
Practice Address - Street 2:
Practice Address - City:PEACE DALE
Practice Address - State:RI
Practice Address - Zip Code:02879-2176
Practice Address - Country:US
Practice Address - Phone:401-487-7042
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-03
Last Update Date:2020-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIMFT00098106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
RIAO54832Medicaid
RI1023290OtherNEIGHBORHOOD HEALTH OF RI
RI27655-1OtherBLUE CROSS
RIFM49368Medicaid
RI411932OtherBLUE CHIP