Provider Demographics
NPI:1861970212
Name:FONTANA, TIMOTHY (LICSW)
Entity type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:
Last Name:FONTANA
Suffix:
Gender:M
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10 FAIRMOUNT ST
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:MA
Mailing Address - Zip Code:01970-1608
Mailing Address - Country:US
Mailing Address - Phone:781-941-0341
Mailing Address - Fax:
Practice Address - Street 1:248 BOSTON ST
Practice Address - Street 2:
Practice Address - City:TOPSFIELD
Practice Address - State:MA
Practice Address - Zip Code:01983-2221
Practice Address - Country:US
Practice Address - Phone:781-941-0341
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-07-29
Last Update Date:2018-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1171188101YS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YS0200XBehavioral Health & Social Service ProvidersCounselorSchool