Provider Demographics
NPI:1720202963
Name:FONTAINE, STEPHEN CHARLES (PT,MPT,DPT)
Entity Type:Individual
Prefix:MR
First Name:STEPHEN
Middle Name:CHARLES
Last Name:FONTAINE
Suffix:
Gender:M
Credentials:PT,MPT,DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18704 WILLOW GROVE RD
Mailing Address - Street 2:
Mailing Address - City:OLNEY
Mailing Address - State:MD
Mailing Address - Zip Code:20832-1226
Mailing Address - Country:US
Mailing Address - Phone:301-774-4728
Mailing Address - Fax:
Practice Address - Street 1:11921 ROCKVILLE PIKE # 404
Practice Address - Street 2:
Practice Address - City:ROCKVILLE
Practice Address - State:MD
Practice Address - Zip Code:20852-2737
Practice Address - Country:US
Practice Address - Phone:301-881-7246
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD19959174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist