Provider Demographics
NPI:1346532843
Name:FOUNTAIN, MICHAEL D (MA, NCC, LAPC)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:D
Last Name:FOUNTAIN
Suffix:
Gender:M
Credentials:MA, NCC, LAPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 491117
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30349-9117
Mailing Address - Country:US
Mailing Address - Phone:678-235-4939
Mailing Address - Fax:770-994-5444
Practice Address - Street 1:1870 ROBLE DRIVE
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30349-9117
Practice Address - Country:US
Practice Address - Phone:678-235-4939
Practice Address - Fax:770-994-5444
Is Sole Proprietor?:Yes
Enumeration Date:2011-05-03
Last Update Date:2011-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA0002892101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional