Provider Demographics
NPI:1356052740
Name:FOUNTAIN BEHAVIORAL SERVICES
Entity type:Organization
Organization Name:FOUNTAIN BEHAVIORAL SERVICES
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ELISE
Authorized Official - Middle Name:
Authorized Official - Last Name:FELICIO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:701-389-9363
Mailing Address - Street 1:21 MAIN ST S
Mailing Address - Street 2:
Mailing Address - City:MINOT
Mailing Address - State:ND
Mailing Address - Zip Code:58701-3890
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:100 MAIN ST S
Practice Address - Street 2:
Practice Address - City:MINOT
Practice Address - State:ND
Practice Address - Zip Code:58701-3914
Practice Address - Country:US
Practice Address - Phone:701-839-9363
Practice Address - Fax:855-955-1279
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ELISE FELICIO BEHAVIOR AND EDUCATION SERVICES PLLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2022-12-07
Last Update Date:2023-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior AnalystGroup - Multi-Specialty
No106S00000XBehavioral Health & Social Service ProvidersBehavior TechnicianGroup - Multi-Specialty