Provider Demographics
NPI:1659097756
Name:FOUNTAIN, MEGAN LOUISE (MA CCC/SLP)
Entity Type:Individual
Prefix:
First Name:MEGAN
Middle Name:LOUISE
Last Name:FOUNTAIN
Suffix:
Gender:F
Credentials:MA CCC/SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2320 LIPIZZAN TRL
Mailing Address - Street 2:
Mailing Address - City:ORMOND BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32174-2517
Mailing Address - Country:US
Mailing Address - Phone:386-679-0159
Mailing Address - Fax:
Practice Address - Street 1:900 N SWALLOW TAIL DR STE 107
Practice Address - Street 2:
Practice Address - City:PORT ORANGE
Practice Address - State:FL
Practice Address - Zip Code:32129-6103
Practice Address - Country:US
Practice Address - Phone:386-679-0159
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-10-19
Last Update Date:2022-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL235Z00000XMedicaid