Provider Demographics
NPI:1457726036
Name:FONTAINE, LAURA (MS, EDS, LISAC, LPC)
Entity Type:Individual
Prefix:
First Name:LAURA
Middle Name:
Last Name:FONTAINE
Suffix:
Gender:F
Credentials:MS, EDS, LISAC, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18445 E PINE VALLEY DR
Mailing Address - Street 2:
Mailing Address - City:QUEEN CREEK
Mailing Address - State:AZ
Mailing Address - Zip Code:85142-3622
Mailing Address - Country:US
Mailing Address - Phone:480-206-4753
Mailing Address - Fax:
Practice Address - Street 1:2345 S ALMA SCHOOL RD STE 105
Practice Address - Street 2:
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85210-4013
Practice Address - Country:US
Practice Address - Phone:480-206-4753
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-12-07
Last Update Date:2019-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLPC-15936101YP2500X
AZLISAC-10622101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)