1750662573 NPI number — MS. MALIA L FONTECCHIO MSW, ACSW

Table of content: MS. MALIA L FONTECCHIO MSW, ACSW (NPI 1750662573)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1750662573 NPI number — MS. MALIA L FONTECCHIO MSW, ACSW

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
FONTECCHIO
Provider First Name:
MALIA
Provider Middle Name:
L
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
MSW, ACSW
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
JAVIER
Provider Other First Name:
MALIA
Provider Other Middle Name:
L
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
MSW
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1750662573
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/16/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
340 HIGHWAY 138
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CRESTLINE
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92325-2449
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
909-336-3330
Provider Business Mailing Address Fax Number:
951-300-4719

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
41945 BIG BEAR BLVD.
Provider Second Line Business Practice Location Address:
SUITE 222
Provider Business Practice Location Address City Name:
BIG BEAR
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92315
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
909-866-5070
Provider Business Practice Location Address Fax Number:
909-878-3228
Provider Enumeration Date:
09/07/2011

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 104100000X , with the licence number:  36499 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 101YM0800X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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