Provider Demographics
NPI:1871632729
Name:FOUNTAIN, SHEPHERD MACDOUGALD (LCSW LCAS)
Entity Type:Individual
Prefix:MS
First Name:SHEPHERD
Middle Name:MACDOUGALD
Last Name:FOUNTAIN
Suffix:
Gender:F
Credentials:LCSW LCAS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:111 EDENBURGH RD
Mailing Address - Street 2:
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27608
Mailing Address - Country:US
Mailing Address - Phone:919-788-8002
Mailing Address - Fax:919-788-0740
Practice Address - Street 1:4010 BARRETT DR
Practice Address - Street 2:STE 101
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27609
Practice Address - Country:US
Practice Address - Phone:919-788-8002
Practice Address - Fax:919-788-0740
Is Sole Proprietor?:No
Enumeration Date:2007-02-06
Last Update Date:2009-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC648LCAS101YA0400X
NCC003525LCSW1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)