Provider Demographics
NPI:1760708689
Name:FONTANA, SALLY ANNE (LCSWR)
Entity Type:Individual
Prefix:MS
First Name:SALLY
Middle Name:ANNE
Last Name:FONTANA
Suffix:
Gender:F
Credentials:LCSWR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1607 ROSER TER
Mailing Address - Street 2:
Mailing Address - City:ROME
Mailing Address - State:NY
Mailing Address - Zip Code:13440-2313
Mailing Address - Country:US
Mailing Address - Phone:315-337-5553
Mailing Address - Fax:
Practice Address - Street 1:227 W DOMINICK ST
Practice Address - Street 2:
Practice Address - City:ROME
Practice Address - State:NY
Practice Address - Zip Code:13440-5853
Practice Address - Country:US
Practice Address - Phone:315-336-6230
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-04-16
Last Update Date:2010-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYRO45353-11041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical