Provider Demographics
NPI:1609029784
Name:FOUNTAINE, KELLY A (MS, CCC-SLP)
Entity Type:Individual
Prefix:MRS
First Name:KELLY
Middle Name:A
Last Name:FOUNTAINE
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 1:16 1ST ST
Mailing Address - Street 2:
Mailing Address - City:HUDSON FALLS
Mailing Address - State:NY
Mailing Address - Zip Code:12839-1516
Mailing Address - Country:US
Mailing Address - Phone:518-409-4246
Mailing Address - Fax:
Practice Address - Street 1:300 BALLARD RD
Practice Address - Street 2:
Practice Address - City:GANSEVOORT
Practice Address - State:NY
Practice Address - Zip Code:12831-1336
Practice Address - Country:US
Practice Address - Phone:518-587-0600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-11-03
Last Update Date:2011-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY015024-1235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist