Provider Demographics
NPI:1285204511
Name:LAFOUNTAIN, EVAN MICHAEL
Entity Type:Individual
Prefix:
First Name:EVAN
Middle Name:MICHAEL
Last Name:LAFOUNTAIN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2822 WALNUT CT
Mailing Address - Street 2:
Mailing Address - City:HUBBARD
Mailing Address - State:OR
Mailing Address - Zip Code:97032-9692
Mailing Address - Country:US
Mailing Address - Phone:219-669-8267
Mailing Address - Fax:
Practice Address - Street 1:805 LIBERTY ST NE STE 2
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97301-2463
Practice Address - Country:US
Practice Address - Phone:219-669-8267
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-06-29
Last Update Date:2021-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health