Provider Demographics
NPI:1861862864
Name:FONTENOT, TINA (MSW)
Entity Type:Individual
Prefix:
First Name:TINA
Middle Name:
Last Name:FONTENOT
Suffix:
Gender:F
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11408 LAKE SHERWOOD AVE N
Mailing Address - Street 2:
Mailing Address - City:BATON ROUGE
Mailing Address - State:LA
Mailing Address - Zip Code:70816-0420
Mailing Address - Country:US
Mailing Address - Phone:225-261-7143
Mailing Address - Fax:225-250-1026
Practice Address - Street 1:11408 LAKE SHERWOOD AVE N STE A
Practice Address - Street 2:
Practice Address - City:BATON ROUGE
Practice Address - State:LA
Practice Address - Zip Code:70816-0421
Practice Address - Country:US
Practice Address - Phone:225-261-7143
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-10-02
Last Update Date:2022-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA11439171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA3700719Medicaid
LA600723334OtherSEASIDE