Provider Demographics
NPI:1326214230
Name:FOUNTAIN, BRYANNE E
Entity Type:Individual
Prefix:
First Name:BRYANNE
Middle Name:E
Last Name:FOUNTAIN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:BRYANNE
Other - Middle Name:E
Other - Last Name:CAROW
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2500 HALL AVENUE
Mailing Address - Street 2:SUITE A
Mailing Address - City:MARINETTE
Mailing Address - State:WI
Mailing Address - Zip Code:54143
Mailing Address - Country:US
Mailing Address - Phone:715-732-7760
Mailing Address - Fax:715-732-7711
Practice Address - Street 1:2500 HALL AVENUE
Practice Address - Street 2:SUITE A
Practice Address - City:MARINETTE
Practice Address - State:WI
Practice Address - Zip Code:54143
Practice Address - Country:US
Practice Address - Phone:715-732-7760
Practice Address - Fax:715-732-7711
Is Sole Proprietor?:No
Enumeration Date:2008-05-01
Last Update Date:2021-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI9013-1231041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical