Healthcare Provider Details

I. General information

NPI: 1336204874
Provider Name (Legal Business Name): REBECCA FONTAINE LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/26/2006
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

710 S BROADWAY
WALNUT CREEK CA
94596-5294
US

IV. Provider business mailing address

PO BOX 658
DANVILLE CA
94526-0658
US

V. Phone/Fax

Practice location:
  • Phone: 925-295-4145
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number141569
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: