Provider Demographics
NPI:1043368806
Name:LA FOUNTAIN, CHARMAIN ROSE ZAPOTOCZNY (MSW)
Entity Type:Individual
Prefix:
First Name:CHARMAIN
Middle Name:ROSE ZAPOTOCZNY
Last Name:LA FOUNTAIN
Suffix:
Gender:F
Credentials:MSW
Other - Prefix:
Other - First Name:CHARMAIN
Other - Middle Name:ROSE
Other - Last Name:ZAPOTOCZNY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LMSW
Mailing Address - Street 1:6 PARKLANE BLVD.
Mailing Address - Street 2:SUITE 695
Mailing Address - City:DEARBORN
Mailing Address - State:MI
Mailing Address - Zip Code:48126
Mailing Address - Country:US
Mailing Address - Phone:313-271-8170
Mailing Address - Fax:
Practice Address - Street 1:6 PARKLANE BLVD
Practice Address - Street 2:SUITE 695
Practice Address - City:DEARBORN
Practice Address - State:MI
Practice Address - Zip Code:48126-2696
Practice Address - Country:US
Practice Address - Phone:313-271-8170
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-08
Last Update Date:2014-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI8008970120OtherBCBSM
MI8008970120OtherBCBSM