Provider Demographics
NPI:1831518976
Name:FONTES, MARTICE
Entity type:Individual
Prefix:
First Name:MARTICE
Middle Name:
Last Name:FONTES
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2271 OVERLAND AVE STE 5
Mailing Address - Street 2:
Mailing Address - City:BURLEY
Mailing Address - State:ID
Mailing Address - Zip Code:83318-2957
Mailing Address - Country:US
Mailing Address - Phone:208-678-9114
Mailing Address - Fax:208-678-8989
Practice Address - Street 1:2271 OVERLAND AVE STE 5
Practice Address - Street 2:
Practice Address - City:BURLEY
Practice Address - State:ID
Practice Address - Zip Code:83318-2957
Practice Address - Country:US
Practice Address - Phone:208-678-9114
Practice Address - Fax:208-678-8989
Is Sole Proprietor?:No
Enumeration Date:2014-04-15
Last Update Date:2014-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLAMFT-5182106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID1376561274Medicaid