Provider Demographics
NPI:1912714536
Name:FONTEYN, LOGAN
Entity type:Individual
Prefix:
First Name:LOGAN
Middle Name:
Last Name:FONTEYN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:31790 US HIGHWAY 19 N APT 185
Mailing Address - Street 2:
Mailing Address - City:PALM HARBOR
Mailing Address - State:FL
Mailing Address - Zip Code:34684-3720
Mailing Address - Country:US
Mailing Address - Phone:813-838-0872
Mailing Address - Fax:
Practice Address - Street 1:5447 E BEAUMONT CENTER BLVD APT 185
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33634-5210
Practice Address - Country:US
Practice Address - Phone:888-754-0398
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-12-17
Last Update Date:2024-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician