Provider Demographics
NPI:1548205453
Name:FOUNTAINE, TIMOTHY JAMES (OTR/L, CLVT)
Entity Type:Individual
Prefix:MR
First Name:TIMOTHY
Middle Name:JAMES
Last Name:FOUNTAINE
Suffix:
Gender:M
Credentials:OTR/L, CLVT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2026 SE 14TH TER
Mailing Address - Street 2:
Mailing Address - City:CAPE CORAL
Mailing Address - State:FL
Mailing Address - Zip Code:33990-3885
Mailing Address - Country:US
Mailing Address - Phone:813-727-5747
Mailing Address - Fax:
Practice Address - Street 1:2026 SE 14TH TER
Practice Address - Street 2:
Practice Address - City:CAPE CORAL
Practice Address - State:FL
Practice Address - Zip Code:33990-3885
Practice Address - Country:US
Practice Address - Phone:813-727-5747
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-17
Last Update Date:2023-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOT11465225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLU8009YMedicare PIN