Provider Demographics
NPI:1295484236
Name:FORTUNA, VICENT M
Entity type:Individual
Prefix:
First Name:VICENT
Middle Name:M
Last Name:FORTUNA
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 1:994 E 180TH ST APT 6C
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10460-2272
Mailing Address - Country:US
Mailing Address - Phone:347-520-1164
Mailing Address - Fax:914-229-2022
Practice Address - Street 1:994 E 180TH ST APT 6C
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10460-2272
Practice Address - Country:US
Practice Address - Phone:347-520-1164
Practice Address - Fax:914-229-2022
Is Sole Proprietor?:Yes
Enumeration Date:2022-03-18
Last Update Date:2022-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY22-203830106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician