Provider Demographics
NPI:1649683848
Name:FOUNTAIN, Y (PHD, LPC, RPT)
Entity type:Individual
Prefix:
First Name:Y
Middle Name:
Last Name:FOUNTAIN
Suffix:
Gender:F
Credentials:PHD, LPC, RPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3545 BROAD ST # 80742
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30341-2259
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1479 BROCKETT RD
Practice Address - Street 2:SUITE 100
Practice Address - City:TUCKER
Practice Address - State:GA
Practice Address - Zip Code:30084-7326
Practice Address - Country:US
Practice Address - Phone:770-375-8124
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-06-04
Last Update Date:2015-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALPC006900101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional