Provider Demographics
NPI:1003148487
Name:FOUNTAIN, KELLY RAWLS (MS, LPT)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:RAWLS
Last Name:FOUNTAIN
Suffix:
Gender:F
Credentials:MS, LPT
Other - Prefix:
Other - First Name:KELLY
Other - Middle Name:ANN
Other - Last Name:RAWLS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2864 DAUPHIN ST
Mailing Address - Street 2:SUITE A
Mailing Address - City:MOBILE
Mailing Address - State:AL
Mailing Address - Zip Code:36606-2479
Mailing Address - Country:US
Mailing Address - Phone:251-470-7607
Mailing Address - Fax:251-470-7609
Practice Address - Street 1:2864 DAUPHIN ST
Practice Address - Street 2:SUITE A
Practice Address - City:MOBILE
Practice Address - State:AL
Practice Address - Zip Code:36606-2479
Practice Address - Country:US
Practice Address - Phone:251-470-7607
Practice Address - Fax:251-470-7609
Is Sole Proprietor?:No
Enumeration Date:2010-02-09
Last Update Date:2013-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL1586101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor