Provider Demographics
NPI:1770842767
Name:FONTENOT, MADELINE (LPC)
Entity Type:Individual
Prefix:
First Name:MADELINE
Middle Name:
Last Name:FONTENOT
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:107 WILD ROSE LN
Mailing Address - Street 2:
Mailing Address - City:YOUNGSVILLE
Mailing Address - State:LA
Mailing Address - Zip Code:70592-5381
Mailing Address - Country:US
Mailing Address - Phone:337-857-6833
Mailing Address - Fax:
Practice Address - Street 1:3 FLAGG PL
Practice Address - Street 2:SUITE A3
Practice Address - City:LAFAYETTE
Practice Address - State:LA
Practice Address - Zip Code:70508-7003
Practice Address - Country:US
Practice Address - Phone:337-857-6833
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-05-10
Last Update Date:2012-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA891101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional