Healthcare Provider Details

I. General information

NPI: 1083755532
Provider Name (Legal Business Name): OBDULIA B FONTANEZ LMSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/09/2007
Last Update Date: 04/05/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1621 EASTCHESTER ROAD
BRONX NY
10461
US

IV. Provider business mailing address

11 W GIBBONS STREET
LINDEN NJ
07036
US

V. Phone/Fax

Practice location:
  • Phone: 718-405-8040
  • Fax: 718-405-8060
Mailing address:
  • Phone: 646-496-6090
  • Fax: 718-405-8060

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number070359
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: