Provider Demographics
NPI:1255861431
Name:FOUNTAIN, LAINE (OTR)
Entity type:Individual
Prefix:MS
First Name:LAINE
Middle Name:
Last Name:FOUNTAIN
Suffix:
Gender:F
Credentials:OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:307 OAK ST
Mailing Address - Street 2:
Mailing Address - City:NEWPORT
Mailing Address - State:NH
Mailing Address - Zip Code:03773-3007
Mailing Address - Country:US
Mailing Address - Phone:401-302-0801
Mailing Address - Fax:
Practice Address - Street 1:43 UNION ST
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:VT
Practice Address - Zip Code:05156-3133
Practice Address - Country:US
Practice Address - Phone:802-885-5155
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-06-19
Last Update Date:2024-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT072.0134375225X00000X
224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
RIOT02201OtherOCCUPATIONAL THERAPIST
VT072.0134375OtherOCCUPATIONAL THERAPIST
NH3541OtherOCCUPATIONAL THERAPIST
495020OtherNBCOT