Provider Demographics
NPI:1730413832
Name:FONTANA, THOMAS JK (MS,LMHC, ADAC)
Entity type:Individual
Prefix:MR
First Name:THOMAS
Middle Name:JK
Last Name:FONTANA
Suffix:
Gender:M
Credentials:MS,LMHC, ADAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5 WOODBINE ST
Mailing Address - Street 2:
Mailing Address - City:SOUTH BURLINGTON
Mailing Address - State:VT
Mailing Address - Zip Code:05403-6622
Mailing Address - Country:US
Mailing Address - Phone:802-862-2390
Mailing Address - Fax:
Practice Address - Street 1:5 WOODBINE ST
Practice Address - Street 2:
Practice Address - City:SOUTH BURLINGTON
Practice Address - State:VT
Practice Address - Zip Code:05403
Practice Address - Country:US
Practice Address - Phone:802-862-2390
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-09-23
Last Update Date:2009-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT068.0053213101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health