Healthcare Provider Details

I. General information

NPI: 1861970212
Provider Name (Legal Business Name): TIMOTHY FONTANA LICSW
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/29/2018
Last Update Date: 07/29/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

248 BOSTON ST
TOPSFIELD MA
01983-2221
US

IV. Provider business mailing address

10 FAIRMOUNT ST
SALEM MA
01970-1608
US

V. Phone/Fax

Practice location:
  • Phone: 781-941-0341
  • Fax:
Mailing address:
  • Phone: 781-941-0341
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YS0200X
TaxonomySchool Counselor
License Number1171188
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: