Provider Demographics
NPI:1013679562
Name:FORTIN, DELANCEY (MA)
Entity Type:Individual
Prefix:
First Name:DELANCEY
Middle Name:
Last Name:FORTIN
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1400 BUFORD HWY STE C1
Mailing Address - Street 2:
Mailing Address - City:BUFORD
Mailing Address - State:GA
Mailing Address - Zip Code:30518-8722
Mailing Address - Country:US
Mailing Address - Phone:470-326-5455
Mailing Address - Fax:
Practice Address - Street 1:1400 BUFORD HWY STE C1
Practice Address - Street 2:
Practice Address - City:BUFORD
Practice Address - State:GA
Practice Address - Zip Code:30518-8722
Practice Address - Country:US
Practice Address - Phone:470-326-5455
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-10-12
Last Update Date:2021-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health