Provider Demographics
NPI:1255861431
Name:FOUNTAIN, LAINE (OTR)
Entity Type:Individual
Prefix:MS
First Name:LAINE
Middle Name:
Last Name:FOUNTAIN
Suffix:
Gender:F
Credentials:OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:702 NH 10
Mailing Address - Street 2:
Mailing Address - City:CROYDON
Mailing Address - State:NH
Mailing Address - Zip Code:03773-2517
Mailing Address - Country:US
Mailing Address - Phone:401-302-0801
Mailing Address - Fax:
Practice Address - Street 1:11 KING CHARLES DR STE A2
Practice Address - Street 2:
Practice Address - City:PORTSMOUTH
Practice Address - State:RI
Practice Address - Zip Code:02871-1364
Practice Address - Country:US
Practice Address - Phone:401-683-8063
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-06-19
Last Update Date:2023-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT072.0134375225X00000X
224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant
No225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VT072.0134375OtherOCCUPATIONAL THERAPIST