Provider Demographics
NPI:1205142502
Name:GILLUNG-FONTANEZ, GRETCHEN (MS, MED)
Entity type:Individual
Prefix:
First Name:GRETCHEN
Middle Name:
Last Name:GILLUNG-FONTANEZ
Suffix:
Gender:F
Credentials:MS, MED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:159 WORCESTER RD STE 103
Mailing Address - Street 2:
Mailing Address - City:CHARLTON
Mailing Address - State:MA
Mailing Address - Zip Code:01507-1677
Mailing Address - Country:US
Mailing Address - Phone:508-469-3184
Mailing Address - Fax:
Practice Address - Street 1:159 WORCESTER RD STE 103
Practice Address - Street 2:
Practice Address - City:CHARLTON
Practice Address - State:MA
Practice Address - Zip Code:01507-1677
Practice Address - Country:US
Practice Address - Phone:508-469-3184
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-08-24
Last Update Date:2022-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
106H00000X
MA1907-MH-MF106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist