Provider Demographics
NPI:1720404528
Name:FOUNTAIN, CYNTHIA LYNETTE (SLP)
Entity Type:Individual
Prefix:MRS
First Name:CYNTHIA
Middle Name:LYNETTE
Last Name:FOUNTAIN
Suffix:
Gender:F
Credentials:SLP
Other - Prefix:MRS
Other - First Name:CINDY
Other - Middle Name:L
Other - Last Name:FOUNTAIN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:SLP
Mailing Address - Street 1:110 TAOS CIR
Mailing Address - Street 2:
Mailing Address - City:WAXAHACHIE
Mailing Address - State:TX
Mailing Address - Zip Code:75165-1512
Mailing Address - Country:US
Mailing Address - Phone:817-689-6263
Mailing Address - Fax:
Practice Address - Street 1:2535 LONE STAR DR
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75212-6313
Practice Address - Country:US
Practice Address - Phone:214-467-9787
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-03-17
Last Update Date:2014-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX19368235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist