Provider Demographics
NPI:1013457589
Name:FORTUNA, ELEANOR
Entity Type:Individual
Prefix:
First Name:ELEANOR
Middle Name:
Last Name:FORTUNA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1274
Mailing Address - Street 2:
Mailing Address - City:OCEAN GATE
Mailing Address - State:NJ
Mailing Address - Zip Code:08740-1274
Mailing Address - Country:US
Mailing Address - Phone:732-232-3137
Mailing Address - Fax:908-928-9367
Practice Address - Street 1:326 E LAKEWOOD AVE
Practice Address - Street 2:
Practice Address - City:OCEAN GATE
Practice Address - State:NJ
Practice Address - Zip Code:08740-1336
Practice Address - Country:US
Practice Address - Phone:732-232-3137
Practice Address - Fax:908-928-9367
Is Sole Proprietor?:Yes
Enumeration Date:2017-03-03
Last Update Date:2017-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ37LC00046500101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)