Provider Demographics
NPI:1578074845
Name:FOUNTAIN, PORTIA L (MS CCC-SLP)
Entity Type:Individual
Prefix:MRS
First Name:PORTIA
Middle Name:L
Last Name:FOUNTAIN
Suffix:
Gender:F
Credentials:MS CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12007 WATER RIDGE DR
Mailing Address - Street 2:
Mailing Address - City:OXFORD
Mailing Address - State:MS
Mailing Address - Zip Code:38655-6015
Mailing Address - Country:US
Mailing Address - Phone:662-801-8064
Mailing Address - Fax:
Practice Address - Street 1:12007 WATER RIDGE DR
Practice Address - Street 2:
Practice Address - City:OXFORD
Practice Address - State:MS
Practice Address - Zip Code:38655-6015
Practice Address - Country:US
Practice Address - Phone:662-801-8064
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-10-13
Last Update Date:2017-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSS2883235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist