MEDICARE: CHARLES R FONTENOT JR. LCDC

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	101YA0400X	Addiction (Substance Use Disorder) Counselor	16043	TX

General Provider Information

NPI Number	:	1619696515
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CHARLES R FONTENOT JR. LCDC

Provider Business Mailing Address
First Line	:	PO BOX 550382
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77255-0382
Country	:	US
Telephone Number	:	281-546-3740
Fax Number	:

Provider Business Practice Location Address
First Line	:	11301 RICHMOND AVE STE K105
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77082-5549
Country	:	US
Telephone Number	:	281-293-9600
Fax Number	:

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

Provider Enumeration Date	:	08/24/2022
Last Update Date	:	08/25/2022

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