Provider Demographics
NPI:1316751068
Name:FORTSON, KEYME J II
Entity type:Individual
Prefix:
First Name:KEYME
Middle Name:J
Last Name:FORTSON
Suffix:II
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 1:1000 BRIDGEPORT AVE
Mailing Address - Street 2:
Mailing Address - City:SHELTON
Mailing Address - State:CT
Mailing Address - Zip Code:06484
Mailing Address - Country:US
Mailing Address - Phone:203-873-7794
Mailing Address - Fax:
Practice Address - Street 1:1000 BRIDGEPORT AVE
Practice Address - Street 2:
Practice Address - City:SHELTON
Practice Address - State:CT
Practice Address - Zip Code:06484
Practice Address - Country:US
Practice Address - Phone:203-993-6592
Practice Address - Fax:475-203-3328
Is Sole Proprietor?:No
Enumeration Date:2025-02-04
Last Update Date:2025-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician