Provider Demographics
NPI:1164829834
Name:FOUNTAIN, ALBA
Entity Type:Individual
Prefix:
First Name:ALBA
Middle Name:
Last Name:FOUNTAIN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:815 PENNY LN
Mailing Address - Street 2:
Mailing Address - City:MOUNT JOY
Mailing Address - State:PA
Mailing Address - Zip Code:17552-9229
Mailing Address - Country:US
Mailing Address - Phone:631-576-6998
Mailing Address - Fax:
Practice Address - Street 1:2501 OREGON PIKE
Practice Address - Street 2:
Practice Address - City:LANCASTER
Practice Address - State:PA
Practice Address - Zip Code:17601-4890
Practice Address - Country:US
Practice Address - Phone:717-449-0076
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-11-24
Last Update Date:2014-11-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PABH002145103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst