Provider Demographics
NPI:1245489392
Name:FONTANEZ, ANGELINA BRENDA (LPC AAP NCC NBCC)
Entity type:Individual
Prefix:
First Name:ANGELINA
Middle Name:BRENDA
Last Name:FONTANEZ
Suffix:
Gender:F
Credentials:LPC AAP NCC NBCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:290 LEE ROAD 309
Mailing Address - Street 2:
Mailing Address - City:PHENIX CITY
Mailing Address - State:AL
Mailing Address - Zip Code:36870-9180
Mailing Address - Country:US
Mailing Address - Phone:706-888-0710
Mailing Address - Fax:
Practice Address - Street 1:1629 10TH AVE STE B
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:GA
Practice Address - Zip Code:31901-3520
Practice Address - Country:US
Practice Address - Phone:706-256-0442
Practice Address - Fax:706-317-2669
Is Sole Proprietor?:Yes
Enumeration Date:2008-09-13
Last Update Date:2011-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA232341101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health