Provider Demographics
NPI:1205263274
Name:FORTUNATO, DANIEL GERARD (M)
Entity type:Individual
Prefix:
First Name:DANIEL
Middle Name:GERARD
Last Name:FORTUNATO
Suffix:
Gender:M
Credentials:M
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:28 WILLIAMS ST
Mailing Address - Street 2:
Mailing Address - City:BEVERLY
Mailing Address - State:MA
Mailing Address - Zip Code:01915-2324
Mailing Address - Country:US
Mailing Address - Phone:978-578-2067
Mailing Address - Fax:
Practice Address - Street 1:28 WILLIAMS ST
Practice Address - Street 2:
Practice Address - City:BEVERLY
Practice Address - State:MA
Practice Address - Zip Code:01915-2324
Practice Address - Country:US
Practice Address - Phone:978-578-2067
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-10-04
Last Update Date:2013-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA302897101Y00000X, 103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
No103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst