Healthcare Provider Details

I. General information

NPI: 1285207225
Provider Name (Legal Business Name): ANDREW FONTANA LMSW
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/19/2021
Last Update Date: 08/05/2022
Certification Date: 08/05/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

19 ELM ST
VERNON CT
06066-3207
US

IV. Provider business mailing address

19 ELM ST
VERNON CT
06066-3207
US

V. Phone/Fax

Practice location:
  • Phone: 860-872-1918
  • Fax:
Mailing address:
  • Phone: 860-872-1918
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number5388
License Number StateCT
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number5388
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: