Provider Demographics
NPI:1538660550
Name:FOUNTAIN-LONDON, YATASCA (COTA)
Entity Type:Individual
Prefix:
First Name:YATASCA
Middle Name:
Last Name:FOUNTAIN-LONDON
Suffix:
Gender:F
Credentials:COTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:313 MAGGIE CIR
Mailing Address - Street 2:
Mailing Address - City:FLINT
Mailing Address - State:TX
Mailing Address - Zip Code:75762-9549
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:313 MAGGIE CIR
Practice Address - Street 2:
Practice Address - City:FLINT
Practice Address - State:TX
Practice Address - Zip Code:75762-9549
Practice Address - Country:US
Practice Address - Phone:903-316-5377
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-02-25
Last Update Date:2018-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant