Provider Demographics
NPI:1073848347
Name:FONTANEZ, IRIS B
Entity type:Individual
Prefix:
First Name:IRIS
Middle Name:B
Last Name:FONTANEZ
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:URB. SANTA MARIA MAYOR 75 C/8 APT. B-9
Mailing Address - Street 2:
Mailing Address - City:HUMACAO
Mailing Address - State:PR
Mailing Address - Zip Code:00791
Mailing Address - Country:US
Mailing Address - Phone:787-852-0768
Mailing Address - Fax:787-656-0735
Practice Address - Street 1:#355 FONT MARTELO AVE.
Practice Address - Street 2:
Practice Address - City:HUMACAO
Practice Address - State:PR
Practice Address - Zip Code:00791
Practice Address - Country:US
Practice Address - Phone:787-852-0768
Practice Address - Fax:787-656-0735
Is Sole Proprietor?:No
Enumeration Date:2009-10-05
Last Update Date:2018-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR2850103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical