Provider Demographics
NPI:1427030857
Name:LAFOUNTAIN, ROBERT KEVIN (MSW, LCSW)
Entity Type:Individual
Prefix:MR
First Name:ROBERT
Middle Name:KEVIN
Last Name:LAFOUNTAIN
Suffix:
Gender:M
Credentials:MSW, LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:N3812 BONEHAM ADDITION RD
Mailing Address - Street 2:
Mailing Address - City:MARINETTE
Mailing Address - State:WI
Mailing Address - Zip Code:54143-9509
Mailing Address - Country:US
Mailing Address - Phone:715-735-0670
Mailing Address - Fax:
Practice Address - Street 1:2500 HALL AVE
Practice Address - Street 2:
Practice Address - City:MARINETTE
Practice Address - State:WI
Practice Address - Zip Code:54143-1604
Practice Address - Country:US
Practice Address - Phone:715-732-7760
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-11-21
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI7110-1231041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI40910500Medicaid