Provider Demographics
NPI:1891850053
Name:FONTAINE, JOAN LEE
Entity Type:Individual
Prefix:MS
First Name:JOAN
Middle Name:LEE
Last Name:FONTAINE
Suffix:
Gender:F
Credentials:
Other - Prefix:MS
Other - First Name:JODY
Other - Middle Name:LEE
Other - Last Name:FONTAINE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:LPC, CAC III
Mailing Address - Street 1:8166 MAPLE DR
Mailing Address - Street 2:
Mailing Address - City:RYE
Mailing Address - State:CO
Mailing Address - Zip Code:81069-8811
Mailing Address - Country:US
Mailing Address - Phone:719-489-3438
Mailing Address - Fax:
Practice Address - Street 1:3500 BALTIMORE AVE
Practice Address - Street 2:
Practice Address - City:PUEBLO
Practice Address - State:CO
Practice Address - Zip Code:81008-1543
Practice Address - Country:US
Practice Address - Phone:719-545-1181
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-27
Last Update Date:2010-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO4236101YA0400X
CO1418101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO4236OtherCAC III
CO1418OtherLPC