Provider Demographics
NPI:1689742462
Name:FORTIN, TONY JOE (LCMHCS, LCAS, CCS)
Entity Type:Individual
Prefix:
First Name:TONY
Middle Name:JOE
Last Name:FORTIN
Suffix:
Gender:M
Credentials:LCMHCS, LCAS, CCS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1203 MAPLE ST
Mailing Address - Street 2:
Mailing Address - City:GREENSBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27405-6910
Mailing Address - Country:US
Mailing Address - Phone:336-641-3934
Mailing Address - Fax:336-641-6193
Practice Address - Street 1:1203 MAPLE ST
Practice Address - Street 2:
Practice Address - City:GREENSBORO
Practice Address - State:NC
Practice Address - Zip Code:27405-6910
Practice Address - Country:US
Practice Address - Phone:336-641-3934
Practice Address - Fax:336-641-6193
Is Sole Proprietor?:No
Enumeration Date:2006-12-01
Last Update Date:2021-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC692101YA0400X
NC2999101YP2500X, 101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6102795Medicaid