Provider Demographics
NPI:1083087175
Name:FOUNTAIN, MONICA ANNE (AUD)
Entity Type:Individual
Prefix:DR
First Name:MONICA
Middle Name:ANNE
Last Name:FOUNTAIN
Suffix:
Gender:F
Credentials:AUD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1043 BEECHWOOD ST NE
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49505-3732
Mailing Address - Country:US
Mailing Address - Phone:248-613-4742
Mailing Address - Fax:
Practice Address - Street 1:13565 PORT SHELDON ST
Practice Address - Street 2:
Practice Address - City:HOLLAND
Practice Address - State:MI
Practice Address - Zip Code:49424-9241
Practice Address - Country:US
Practice Address - Phone:616-738-8940
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-11-11
Last Update Date:2020-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI1601000718231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist