Basic Information
| Provider Information | |||||||||
| NPI: | 1750662573 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | FONTECCHIO | ||||||||
| FirstName: | MALIA | ||||||||
| MiddleName: | L | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MSW, ACSW | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | JAVIER | ||||||||
| OtherFirstName: | MALIA | ||||||||
| OtherMiddleName: | L | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | MSW | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 340 HIGHWAY 138 | ||||||||
| Address2: | |||||||||
| City: | CRESTLINE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 923252449 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9093363330 | ||||||||
| FaxNumber: | 9513004719 | ||||||||
| Practice Location | |||||||||
| Address1: | 41945 BIG BEAR BLVD. | ||||||||
| Address2: | SUITE 222 | ||||||||
| City: | BIG BEAR | ||||||||
| State: | CA | ||||||||
| PostalCode: | 92315 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9098665070 | ||||||||
| FaxNumber: | 9098783228 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/07/2011 | ||||||||
| LastUpdateDate: | 08/16/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 104100000X | 36499 | CA | N | Behavioral Health & Social Service Providers | Social Worker | 101YM0800X | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
No ID Information.