Provider Demographics
NPI:1780482307
Name:FOUNTAIN, MENPLAY
Entity type:Individual
Prefix:
First Name:MENPLAY
Middle Name:
Last Name:FOUNTAIN
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:61 DAVIS AVE
Mailing Address - Street 2:
Mailing Address - City:NEPTUNE
Mailing Address - State:NJ
Mailing Address - Zip Code:07753-4401
Mailing Address - Country:US
Mailing Address - Phone:732-897-2820
Mailing Address - Fax:732-869-9798
Practice Address - Street 1:61 DAVIS AVE
Practice Address - Street 2:
Practice Address - City:NEPTUNE
Practice Address - State:NJ
Practice Address - Zip Code:07753-4401
Practice Address - Country:US
Practice Address - Phone:732-897-2820
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-03-07
Last Update Date:2025-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ44SL06921000104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker