Provider Demographics
NPI:1457195489
Name:FONTANEZ, BIANCA (MA LMHC)
Entity type:Individual
Prefix:
First Name:BIANCA
Middle Name:
Last Name:FONTANEZ
Suffix:
Gender:F
Credentials:MA LMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6215 MAHAFFEY RD UNIT 202
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33966-1654
Mailing Address - Country:US
Mailing Address - Phone:239-440-8730
Mailing Address - Fax:
Practice Address - Street 1:22904 LYDEN DR UNIT 104
Practice Address - Street 2:
Practice Address - City:ESTERO
Practice Address - State:FL
Practice Address - Zip Code:33928-7048
Practice Address - Country:US
Practice Address - Phone:239-494-3951
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-06-24
Last Update Date:2024-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL22681101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health