Provider Demographics
NPI:1063746022
Name:WOOTEN, CAROL G FOUNTAIN (MA)
Entity type:Individual
Prefix:
First Name:CAROL
Middle Name:G FOUNTAIN
Last Name:WOOTEN
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1709 LEGION RD
Mailing Address - Street 2:SUITE 224
Mailing Address - City:CHAPEL HILL
Mailing Address - State:NC
Mailing Address - Zip Code:27517-2375
Mailing Address - Country:US
Mailing Address - Phone:919-928-3611
Mailing Address - Fax:919-929-8006
Practice Address - Street 1:1709 LEGION RD
Practice Address - Street 2:SUITE 224
Practice Address - City:CHAPEL HILL
Practice Address - State:NC
Practice Address - Zip Code:27517-2375
Practice Address - Country:US
Practice Address - Phone:919-928-3611
Practice Address - Fax:919-929-8006
Is Sole Proprietor?:No
Enumeration Date:2009-09-23
Last Update Date:2010-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC6079A106H00000X
NC7939101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist