Provider Demographics
NPI:1013665454
Name:FORTINO, MAKINIE
Entity Type:Individual
Prefix:
First Name:MAKINIE
Middle Name:
Last Name:FORTINO
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 1:4333 NE 22ND CT
Mailing Address - Street 2:
Mailing Address - City:RENTON
Mailing Address - State:WA
Mailing Address - Zip Code:98059-3648
Mailing Address - Country:US
Mailing Address - Phone:786-897-6714
Mailing Address - Fax:
Practice Address - Street 1:4333 NE 22ND CT
Practice Address - Street 2:
Practice Address - City:RENTON
Practice Address - State:WA
Practice Address - Zip Code:98059-3648
Practice Address - Country:US
Practice Address - Phone:971-600-1735
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-03-15
Last Update Date:2022-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WALF60640108106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist