Provider Demographics
NPI:1730647553
Name:FORTUNATO, HAROLD (LAC)
Entity Type:Individual
Prefix:MR
First Name:HAROLD
Middle Name:
Last Name:FORTUNATO
Suffix:
Gender:M
Credentials:LAC
Other - Prefix:MR
Other - First Name:HAROLD
Other - Middle Name:D
Other - Last Name:FORTUNATO
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LAC
Mailing Address - Street 1:7 RUBY PL
Mailing Address - Street 2:
Mailing Address - City:NEWARK
Mailing Address - State:NJ
Mailing Address - Zip Code:07104-2413
Mailing Address - Country:US
Mailing Address - Phone:973-960-1726
Mailing Address - Fax:
Practice Address - Street 1:34 LOWRY CT APT D
Practice Address - Street 2:
Practice Address - City:CLIFTON
Practice Address - State:NJ
Practice Address - Zip Code:07012-3349
Practice Address - Country:US
Practice Address - Phone:973-960-1726
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-03-11
Last Update Date:2019-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ37AC00354600101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Single Specialty