Provider Demographics
NPI:1104515014
Name:SECOY FONTANA, PATRICIA (LCSW)
Entity type:Individual
Prefix:
First Name:PATRICIA
Middle Name:
Last Name:SECOY FONTANA
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:445 E LANGSNER ST
Mailing Address - Street 2:
Mailing Address - City:ENGLEWOOD
Mailing Address - State:FL
Mailing Address - Zip Code:34223-3454
Mailing Address - Country:US
Mailing Address - Phone:314-974-7347
Mailing Address - Fax:
Practice Address - Street 1:9962 LIN FERRY DR
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63123-6974
Practice Address - Country:US
Practice Address - Phone:626-888-1112
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-05-05
Last Update Date:2023-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO20060162501041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical