Provider Demographics
NPI:1043987647
Name:FOUNTAIN, CAROLINE GORDY (PHYSICAL THERAPIST)
Entity Type:Individual
Prefix:MS
First Name:CAROLINE
Middle Name:GORDY
Last Name:FOUNTAIN
Suffix:
Gender:F
Credentials:PHYSICAL THERAPIST
Other - Prefix:
Other - First Name:CAROLINE
Other - Middle Name:
Other - Last Name:GORDY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:921 WEST BEACON STREET
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:MS
Mailing Address - Zip Code:39350
Mailing Address - Country:US
Mailing Address - Phone:601-650-0002
Mailing Address - Fax:601-650-9902
Practice Address - Street 1:13010 HWY 18
Practice Address - Street 2:
Practice Address - City:RAYMOND
Practice Address - State:MS
Practice Address - Zip Code:39154-9526
Practice Address - Country:US
Practice Address - Phone:601-857-2229
Practice Address - Fax:601-857-8223
Is Sole Proprietor?:No
Enumeration Date:2021-08-23
Last Update Date:2023-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSPT7134225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist