Provider Demographics
NPI:1356901540
Name:FONTENOT, CLARA I
Entity type:Individual
Prefix:
First Name:CLARA
Middle Name:I
Last Name:FONTENOT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:CLARISOL
Other - Middle Name:I
Other - Last Name:FONTENOT
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:LCDC, LPC INTERN
Mailing Address - Street 1:24222 LAKE PATH CIR
Mailing Address - Street 2:
Mailing Address - City:KATY
Mailing Address - State:TX
Mailing Address - Zip Code:77493-2544
Mailing Address - Country:US
Mailing Address - Phone:337-529-6380
Mailing Address - Fax:
Practice Address - Street 1:903A AVENUE D
Practice Address - Street 2:
Practice Address - City:KATY
Practice Address - State:TX
Practice Address - Zip Code:77493-2325
Practice Address - Country:US
Practice Address - Phone:713-489-6240
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-06-19
Last Update Date:2019-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX14366101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)