Provider Demographics
NPI:1710175161
Name:FONTANEZ, ANGELICA (LCSW)
Entity Type:Individual
Prefix:MISS
First Name:ANGELICA
Middle Name:
Last Name:FONTANEZ
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1817 BLACK ROCK TPKE
Mailing Address - Street 2:SUITE 102
Mailing Address - City:FAIRFIELD
Mailing Address - State:CT
Mailing Address - Zip Code:06825-3546
Mailing Address - Country:US
Mailing Address - Phone:203-275-8555
Mailing Address - Fax:
Practice Address - Street 1:1817 BLACK ROCK TPKE
Practice Address - Street 2:SUITE 102
Practice Address - City:FAIRFIELD
Practice Address - State:CT
Practice Address - Zip Code:06825-3546
Practice Address - Country:US
Practice Address - Phone:203-275-8555
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-10-11
Last Update Date:2011-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT0065131041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical