Basic Information
| Provider Information | |||||||||
| NPI: | 1871900258 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | FONTANA | ||||||||
| FirstName: | LAUREN | ||||||||
| MiddleName: | |||||||||
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| Credential: | LPC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1 LONG WHARF DR | ||||||||
| Address2: | |||||||||
| City: | NEW HAVEN | ||||||||
| State: | CT | ||||||||
| PostalCode: | 065115946 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2037814600 | ||||||||
| FaxNumber: | 2037814624 | ||||||||
| Practice Location | |||||||||
| Address1: | 425 GRANT ST | ||||||||
| Address2: | |||||||||
| City: | BRIDGEPORT | ||||||||
| State: | CT | ||||||||
| PostalCode: | 066103222 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2037814600 | ||||||||
| FaxNumber: | 2037814624 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/17/2014 | ||||||||
| LastUpdateDate: | 08/22/2014 | ||||||||
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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 | 101YP2500X | 002554 | CT | Y | Behavioral Health & Social Service Providers | Counselor | Professional |
ID Information
| ID | Type | State | Issuer | Description | 008023170 | 05 | CT | MEDICAID | 008042339 | 05 | CT | MEDICAID | 008053322 | 01 | CT | MEDICAID # FONTANA | OTHER | 008024427 | 05 | CT | MEDICAID |