Provider Demographics
NPI:1720186869
Name:FONTENOT, TINA M (MS)
Entity Type:Individual
Prefix:
First Name:TINA
Middle Name:M
Last Name:FONTENOT
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1301 HIGHWAY 96
Mailing Address - Street 2:
Mailing Address - City:LEAGUE CITY
Mailing Address - State:TX
Mailing Address - Zip Code:77573-6313
Mailing Address - Country:US
Mailing Address - Phone:281-724-9792
Mailing Address - Fax:
Practice Address - Street 1:1301 HIGHWAY 96
Practice Address - Street 2:
Practice Address - City:LEAGUE CITY
Practice Address - State:TX
Practice Address - Zip Code:77573-6313
Practice Address - Country:US
Practice Address - Phone:281-724-9792
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-20
Last Update Date:2010-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV1182101YP2500X
WV768103T00000X
TX66102101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV9205105000Medicaid
WVWA4181521Medicare ID - Type Unspecified