Healthcare Provider Details

I. General information

NPI: 1902007792
Provider Name (Legal Business Name): DAVID MARC LAFONTAINE LCSW-R
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/30/2007
Last Update Date: 03/28/2023
Certification Date: 03/28/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

86 MDG UNIT 3215 RAMSTEIN AB
APO AE
09094
US

IV. Provider business mailing address

PSC 2 BOX 14745
APO AE
09012-0148
US

V. Phone/Fax

Practice location:
  • Phone: 314-479-1007
  • Fax:
Mailing address:
  • Phone: 314-479-1007
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number035038
License Number StateNY
# 3
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberR035038-1
License Number StateNY
# 4
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberR035038
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: