Provider Demographics
NPI:1104122977
Name:FOUNTAIN, ASHLEY
Entity type:Individual
Prefix:
First Name:ASHLEY
Middle Name:
Last Name:FOUNTAIN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:425 GARDINER RD
Mailing Address - Street 2:
Mailing Address - City:HOMER
Mailing Address - State:GA
Mailing Address - Zip Code:30547-3006
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:425 GARDINER RD
Practice Address - Street 2:
Practice Address - City:HOMER
Practice Address - State:GA
Practice Address - Zip Code:30547-3006
Practice Address - Country:US
Practice Address - Phone:706-658-7656
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-01-26
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAOT005179225X00000X
OHOT009376225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist