Provider Demographics
NPI:1477562023
Name:LAFOUNTAIN, GEORGE LOUIS JR (MSW LCSW)
Entity Type:Individual
Prefix:MR
First Name:GEORGE
Middle Name:LOUIS
Last Name:LAFOUNTAIN
Suffix:JR
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 1:12 NEWMAN AVE
Mailing Address - Street 2:
Mailing Address - City:NUTLEY
Mailing Address - State:NJ
Mailing Address - Zip Code:07110-2126
Mailing Address - Country:US
Mailing Address - Phone:201-444-4228
Mailing Address - Fax:973-667-8147
Practice Address - Street 1:65 N MAPLE AVE
Practice Address - Street 2:#208
Practice Address - City:RIDGEWOOD
Practice Address - State:NJ
Practice Address - Zip Code:07450
Practice Address - Country:US
Practice Address - Phone:201-444-4228
Practice Address - Fax:973-667-8147
Is Sole Proprietor?:No
Enumeration Date:2006-08-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ44SC001509001041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
701252Medicare ID - Type Unspecified