Provider Demographics
NPI:1871837179
Name:FONTEIN, GEORGINA NOEMI (MA MFT INTERN)
Entity Type:Individual
Prefix:MRS
First Name:GEORGINA
Middle Name:NOEMI
Last Name:FONTEIN
Suffix:
Gender:F
Credentials:MA MFT INTERN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1045 N GENESEE AVE APT 6
Mailing Address - Street 2:
Mailing Address - City:WEST HOLLYWOOD
Mailing Address - State:CA
Mailing Address - Zip Code:90046-6274
Mailing Address - Country:US
Mailing Address - Phone:949-310-3634
Mailing Address - Fax:
Practice Address - Street 1:323 N PRAIRIE AVE
Practice Address - Street 2:
Practice Address - City:INGLEWOOD
Practice Address - State:CA
Practice Address - Zip Code:90301-4502
Practice Address - Country:US
Practice Address - Phone:949-310-3634
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-11-27
Last Update Date:2016-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist