MEDICARE: GLORIA ESTHER FONTES LCSW

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101Y00000X	Counselor	LCSW81836	CA
2	101YP2500X	Professional Counselor	ASW 30541	CA
3	1041C0700X	Clinical Social Worker	LCSW81836	CA

General Provider Information

NPI Number	:	1902164304
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	GLORIA ESTHER FONTES LCSW

Provider Business Mailing Address
First Line	:	800 SCENIC DR
Second Line	:
City	:	MODESTO
State	:	CA
Zip	:	95350-6131
Country	:	US
Telephone Number	:	209-525-5157
Fax Number	:

Provider Business Practice Location Address
First Line	:	29101 HOSPITAL RD
Second Line	:
City	:	LAKE ARROWHEAD
State	:	CA
Zip	:	92352-9706
Country	:	US
Telephone Number	:	909-436-3235
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/24/2012
Last Update Date	:	01/26/2024

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