Provider Demographics
NPI:1629846464
Name:FONTAINE, ALYSSA (CSW)
Entity type:Individual
Prefix:
First Name:ALYSSA
Middle Name:
Last Name:FONTAINE
Suffix:
Gender:F
Credentials:CSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:239 ELM ST NE
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87102-3672
Mailing Address - Country:US
Mailing Address - Phone:505-242-1010
Mailing Address - Fax:505-242-1551
Practice Address - Street 1:1709 MOON ST NE
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87112-3935
Practice Address - Country:US
Practice Address - Phone:505-271-0329
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-12-12
Last Update Date:2025-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
172V00000X
NMNA171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Yes172V00000XOther Service ProvidersCommunity Health Worker