Provider Demographics
NPI:1396881934
Name:FONTANEZ, LUIS EDGARDO
Entity type:Individual
Prefix:MR
First Name:LUIS
Middle Name:EDGARDO
Last Name:FONTANEZ
Suffix:
Gender:M
Credentials:
Other - Prefix:MR
Other - First Name:LUIS
Other - Middle Name:EDGARDO
Other - Last Name:FONTANEZ
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LCSW
Mailing Address - Street 1:2440 BOSTON RD APT 4B
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10467-9042
Mailing Address - Country:US
Mailing Address - Phone:646-667-2482
Mailing Address - Fax:
Practice Address - Street 1:3424 KOSSUTH AVENUE
Practice Address - Street 2:NORTH CENTRAL BRONX HOSPITAL
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10467
Practice Address - Country:US
Practice Address - Phone:718-519-3345
Practice Address - Fax:718-519-4892
Is Sole Proprietor?:No
Enumeration Date:2007-01-30
Last Update Date:2011-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0426541041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY042654OtherPROFESSIONAL LICENSE #