Provider Demographics
NPI:1255708269
Name:FONVILLE, CARLTON
Entity type:Individual
Prefix:MR
First Name:CARLTON
Middle Name:
Last Name:FONVILLE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8101 SANDY SPRING RD STE 250
Mailing Address - Street 2:
Mailing Address - City:LAUREL
Mailing Address - State:MD
Mailing Address - Zip Code:20707-3527
Mailing Address - Country:US
Mailing Address - Phone:301-909-3887
Mailing Address - Fax:443-279-2793
Practice Address - Street 1:8101 SANDY SPRING RD STE 250
Practice Address - Street 2:
Practice Address - City:LAUREL
Practice Address - State:MD
Practice Address - Zip Code:20707-3527
Practice Address - Country:US
Practice Address - Phone:301-909-3887
Practice Address - Fax:443-279-2793
Is Sole Proprietor?:Yes
Enumeration Date:2015-08-25
Last Update Date:2022-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD171971041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical