Provider Demographics
NPI:1063902849
Name:FOUNTAIN, REBECCA (LPA)
Entity type:Individual
Prefix:
First Name:REBECCA
Middle Name:
Last Name:FOUNTAIN
Suffix:
Gender:F
Credentials:LPA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1640 JEFFERSON ST APT 203
Mailing Address - Street 2:
Mailing Address - City:PADUCAH
Mailing Address - State:KY
Mailing Address - Zip Code:42001-2721
Mailing Address - Country:US
Mailing Address - Phone:270-559-9547
Mailing Address - Fax:
Practice Address - Street 1:425 BROADWAY ST
Practice Address - Street 2:
Practice Address - City:PADUCAH
Practice Address - State:KY
Practice Address - Zip Code:42001-0713
Practice Address - Country:US
Practice Address - Phone:270-442-9767
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-05-16
Last Update Date:2018-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY174287103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical