Provider Demographics
NPI:1669721577
Name:FANTUCCHIO, SCOTT DONALD (MA)
Entity type:Individual
Prefix:
First Name:SCOTT
Middle Name:DONALD
Last Name:FANTUCCHIO
Suffix:
Gender:M
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:138 BROAD ST APT 2
Mailing Address - Street 2:
Mailing Address - City:NORTH ATTLEBORO
Mailing Address - State:MA
Mailing Address - Zip Code:02760-1178
Mailing Address - Country:US
Mailing Address - Phone:781-424-2602
Mailing Address - Fax:
Practice Address - Street 1:1 WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:TAUNTON
Practice Address - State:MA
Practice Address - Zip Code:02780-3960
Practice Address - Country:US
Practice Address - Phone:508-977-8024
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-09-06
Last Update Date:2012-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health