Provider Demographics
NPI:1740977743
Name:FORTUNAT, CHAMANDRE J
Entity type:Individual
Prefix:
First Name:CHAMANDRE
Middle Name:J
Last Name:FORTUNAT
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 1:282 CRESCENT ST
Mailing Address - Street 2:
Mailing Address - City:WEST BRIDGEWATER
Mailing Address - State:MA
Mailing Address - Zip Code:02379-1424
Mailing Address - Country:US
Mailing Address - Phone:508-315-2607
Mailing Address - Fax:
Practice Address - Street 1:282 CRESCENT ST
Practice Address - Street 2:
Practice Address - City:WEST BRIDGEWATER
Practice Address - State:MA
Practice Address - Zip Code:02379-1424
Practice Address - Country:US
Practice Address - Phone:508-315-2607
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-04-19
Last Update Date:2023-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA4584224ZE0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224ZE0001XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy AssistantEnvironmental Modification