Provider Demographics
NPI:1184776312
Name:FONTANA, MICHAEL (LMFT)
Entity type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:
Last Name:FONTANA
Suffix:
Gender:M
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13 FRESH MEADOW RD
Mailing Address - Street 2:
Mailing Address - City:EASTON
Mailing Address - State:CT
Mailing Address - Zip Code:06612-2215
Mailing Address - Country:US
Mailing Address - Phone:203-259-8998
Mailing Address - Fax:
Practice Address - Street 1:13 FRESH MEADOW RD
Practice Address - Street 2:
Practice Address - City:EASTON
Practice Address - State:CT
Practice Address - Zip Code:06612-2215
Practice Address - Country:US
Practice Address - Phone:203-259-8998
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-17
Last Update Date:2019-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT001013106H00000X
CTCT 001013106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT270023827OtherTAX ID