Provider Demographics
NPI:1952508764
Name:FONTAINE, EDMUND VINCENT (MS)
Entity Type:Individual
Prefix:MR
First Name:EDMUND
Middle Name:VINCENT
Last Name:FONTAINE
Suffix:
Gender:M
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3230 EVERETT DR
Mailing Address - Street 2:
Mailing Address - City:EDMOND
Mailing Address - State:OK
Mailing Address - Zip Code:73013-7441
Mailing Address - Country:US
Mailing Address - Phone:405-475-0233
Mailing Address - Fax:
Practice Address - Street 1:4436 NW 50TH ST
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73112-2212
Practice Address - Country:US
Practice Address - Phone:405-858-2700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-06-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK101YS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YS0200XBehavioral Health & Social Service ProvidersCounselorSchool