Provider Demographics
NPI:1750662573
Name:FONTECCHIO, MALIA L (MSW, ACSW)
Entity Type:Individual
Prefix:MS
First Name:MALIA
Middle Name:L
Last Name:FONTECCHIO
Suffix:
Gender:F
Credentials:MSW, ACSW
Other - Prefix:
Other - First Name:MALIA
Other - Middle Name:L
Other - Last Name:JAVIER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MSW
Mailing Address - Street 1:340 HIGHWAY 138
Mailing Address - Street 2:
Mailing Address - City:CRESTLINE
Mailing Address - State:CA
Mailing Address - Zip Code:92325-2449
Mailing Address - Country:US
Mailing Address - Phone:909-336-3330
Mailing Address - Fax:951-300-4719
Practice Address - Street 1:41945 BIG BEAR BLVD.
Practice Address - Street 2:SUITE 222
Practice Address - City:BIG BEAR
Practice Address - State:CA
Practice Address - Zip Code:92315
Practice Address - Country:US
Practice Address - Phone:909-866-5070
Practice Address - Fax:909-878-3228
Is Sole Proprietor?:No
Enumeration Date:2011-09-07
Last Update Date:2018-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA36499104100000X
101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No104100000XBehavioral Health & Social Service ProvidersSocial Worker