Provider Demographics
NPI:1750973723
Name:FOUNTAIN, BETH A (LMT)
Entity type:Individual
Prefix:
First Name:BETH
Middle Name:A
Last Name:FOUNTAIN
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 895
Mailing Address - Street 2:
Mailing Address - City:GIRDWOOD
Mailing Address - State:AK
Mailing Address - Zip Code:99587-0895
Mailing Address - Country:US
Mailing Address - Phone:269-718-9736
Mailing Address - Fax:
Practice Address - Street 1:311 SAINT MORITZ
Practice Address - Street 2:
Practice Address - City:GIRDWOOD
Practice Address - State:AK
Practice Address - Zip Code:99587
Practice Address - Country:US
Practice Address - Phone:269-718-9736
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-02-10
Last Update Date:2021-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK110936225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist