Provider Demographics
NPI:1417402017
Name:FONTAINE, KORIN YVETTE
Entity Type:Individual
Prefix:
First Name:KORIN
Middle Name:YVETTE
Last Name:FONTAINE
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 1:2415 S CATLIN ST
Mailing Address - Street 2:
Mailing Address - City:MISSOULA
Mailing Address - State:MT
Mailing Address - Zip Code:59801-7822
Mailing Address - Country:US
Mailing Address - Phone:406-549-0114
Mailing Address - Fax:406-549-0267
Practice Address - Street 1:2415 S CATLIN ST
Practice Address - Street 2:
Practice Address - City:MISSOULA
Practice Address - State:MT
Practice Address - Zip Code:59801-7822
Practice Address - Country:US
Practice Address - Phone:406-549-0114
Practice Address - Fax:406-549-0267
Is Sole Proprietor?:No
Enumeration Date:2016-08-24
Last Update Date:2023-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MTBBH-LCSW-LIC-636651041C0700X
1041S0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041S0200XBehavioral Health & Social Service ProvidersSocial WorkerSchool
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical