Provider Demographics
NPI:1811203029
Name:FONTENOT, MICHELLE DEON (MED)
Entity Type:Individual
Prefix:MS
First Name:MICHELLE
Middle Name:DEON
Last Name:FONTENOT
Suffix:
Gender:F
Credentials:MED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3703 S EDMUNDS ST
Mailing Address - Street 2:#20
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98118-1728
Mailing Address - Country:US
Mailing Address - Phone:206-280-8613
Mailing Address - Fax:
Practice Address - Street 1:3703 S EDMUNDS ST
Practice Address - Street 2:#20
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98118-1728
Practice Address - Country:US
Practice Address - Phone:206-280-8613
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-08-25
Last Update Date:2010-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WALH00006340101YM0800X, 106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist