Provider Demographics
NPI:1194244244
Name:FANTOZZI, ALEXANDRIA MARIE
Entity type:Individual
Prefix:
First Name:ALEXANDRIA
Middle Name:MARIE
Last Name:FANTOZZI
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 1:25 IKEA DR
Mailing Address - Street 2:
Mailing Address - City:WESTAMPTON
Mailing Address - State:NJ
Mailing Address - Zip Code:08060-5115
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:112 N BROAD ST
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19102-1512
Practice Address - Country:US
Practice Address - Phone:215-568-0860
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-09-10
Last Update Date:2024-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
PACW0232681041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health