Healthcare Provider Details

I. General information

NPI: 1104515014
Provider Name (Legal Business Name): PATRICIA SECOY FONTANA LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/05/2023
Last Update Date: 05/05/2023
Certification Date: 05/05/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9962 LIN FERRY DR
SAINT LOUIS MO
63123-6974
US

IV. Provider business mailing address

445 E LANGSNER ST
ENGLEWOOD FL
34223-3454
US

V. Phone/Fax

Practice location:
  • Phone: 626-888-1112
  • Fax:
Mailing address:
  • Phone: 314-974-7347
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number2006016250
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: