Provider Demographics
NPI:1124717194
Name:COATES FOUNTAIN, WANDA DENISE
Entity type:Individual
Prefix:
First Name:WANDA DENISE
Middle Name:
Last Name:COATES 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 1:151 LAFAYETTE ST
Mailing Address - Street 2:
Mailing Address - City:PONTIAC
Mailing Address - State:MI
Mailing Address - Zip Code:48342-2082
Mailing Address - Country:US
Mailing Address - Phone:586-222-2244
Mailing Address - Fax:
Practice Address - Street 1:17345 15 MILE RD
Practice Address - Street 2:
Practice Address - City:CLINTON TOWNSHIP
Practice Address - State:MI
Practice Address - Zip Code:48035-2301
Practice Address - Country:US
Practice Address - Phone:586-222-2244
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-05-04
Last Update Date:2023-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6802073300104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker