Provider Demographics
NPI:1952465312
Name:FONTENOT, RICHARD (MA, MFT)
Entity Type:Individual
Prefix:MR
First Name:RICHARD
Middle Name:
Last Name:FONTENOT
Suffix:
Gender:M
Credentials:MA, MFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:608 S ST ANDREWS PL
Mailing Address - Street 2:PENTHOUSE 509
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90005-3098
Mailing Address - Country:US
Mailing Address - Phone:323-981-4301
Mailing Address - Fax:
Practice Address - Street 1:1500 S MCDONNELL AVE
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90040-5623
Practice Address - Country:US
Practice Address - Phone:323-981-4301
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-20
Last Update Date:2009-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA48187101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health