Provider Demographics
NPI:1104267913
Name:FOUNTAIN, MELISSA ROREX (LCSW)
Entity type:Individual
Prefix:
First Name:MELISSA
Middle Name:ROREX
Last Name:FOUNTAIN
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9064 HIGHWAY 431 S
Mailing Address - Street 2:P. O BOX 305
Mailing Address - City:OWENS CROSS ROADS
Mailing Address - State:AL
Mailing Address - Zip Code:35763-8932
Mailing Address - Country:US
Mailing Address - Phone:256-725-3722
Mailing Address - Fax:208-498-4045
Practice Address - Street 1:9064 HIGHWAY 431 S
Practice Address - Street 2:
Practice Address - City:OWENS CROSS ROADS
Practice Address - State:AL
Practice Address - Zip Code:35763-8932
Practice Address - Country:US
Practice Address - Phone:256-725-3722
Practice Address - Fax:208-498-4045
Is Sole Proprietor?:No
Enumeration Date:2013-07-09
Last Update Date:2015-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL1450C1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical