Provider Demographics
NPI:1245018969
Name:FORTUNA, ANTHONY (PSYD)
Entity type:Individual
Prefix:
First Name:ANTHONY
Middle Name:
Last Name:FORTUNA
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:63 BERESFORD AVE
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10314-4700
Mailing Address - Country:US
Mailing Address - Phone:347-939-2527
Mailing Address - Fax:
Practice Address - Street 1:151 KNOLLCROFT RD
Practice Address - Street 2:
Practice Address - City:LYONS
Practice Address - State:NJ
Practice Address - Zip Code:07939-5001
Practice Address - Country:US
Practice Address - Phone:908-647-0180
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-09-15
Last Update Date:2023-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ35SI00724700103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical