Healthcare Provider Details

I. General information

NPI: 1710441209
Provider Name (Legal Business Name): KAREN ANN FONTAINE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/29/2019
Last Update Date: 01/29/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

87 PHELPS RD
MANCHESTER CT
06042-3209
US

IV. Provider business mailing address

87 PHELPS RD
MANCHESTER CT
06042-3209
US

V. Phone/Fax

Practice location:
  • Phone: 860-614-2388
  • Fax:
Mailing address:
  • Phone: 860-614-2388
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number StateCT
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL
# 3
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: