MEDICARE: JUANITA FONTENOT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	104100000X	Social Worker	LG200002703	DC
2	104100000X	Social Worker	27471	MD
3	1041C0700X	Clinical Social Worker	LC200003459	DC
4	1041C0700X	Clinical Social Worker	27471	MD

General Provider Information

NPI Number	:	1245063981
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JUANITA FONTENOT

Provider Business Mailing Address
First Line	:	5820 YORK RD STE 201
Second Line	:
City	:	BALTIMORE
State	:	MD
Zip	:	21212-3620
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	3934 TYNEWICK DR
Second Line	:
City	:	SILVER SPRING
State	:	MD
Zip	:	20906-2666
Country	:	US
Telephone Number	:	202-763-9124
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/20/2024
Last Update Date	:	05/05/2025

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Directions to “ JUANITA FONTENOT ” Practice Location

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