Provider Demographics
NPI:1801231147
Name:VELASCO FONTAINE, MARIA ELENA (MS)
Entity Type:Individual
Prefix:
First Name:MARIA
Middle Name:ELENA
Last Name:VELASCO FONTAINE
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:MARIA
Other - Middle Name:ELENA
Other - Last Name:FONTAINE VELASCO
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MS
Mailing Address - Street 1:2908 AMBER OAK DR
Mailing Address - Street 2:
Mailing Address - City:VALRICO
Mailing Address - State:FL
Mailing Address - Zip Code:33594-6740
Mailing Address - Country:US
Mailing Address - Phone:813-472-6893
Mailing Address - Fax:
Practice Address - Street 1:6152 DELANCEY STATION ST STE 206
Practice Address - Street 2:
Practice Address - City:RIVERVIEW
Practice Address - State:FL
Practice Address - Zip Code:33578-4206
Practice Address - Country:US
Practice Address - Phone:813-285-7524
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-04-30
Last Update Date:2020-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMH13552101YM0800X
FLIMH10933101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health