Provider Demographics
NPI:1396281077
Name:TISHLINN S FOUNTAIN, LLC
Entity type:Organization
Organization Name:TISHLINN S FOUNTAIN, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:TISHLINN
Authorized Official - Middle Name:S
Authorized Official - Last Name:FOUNTAIN
Authorized Official - Suffix:
Authorized Official - Credentials:LPC
Authorized Official - Phone:504-312-9388
Mailing Address - Street 1:401 WHITNEY AVE
Mailing Address - Street 2:STE 409
Mailing Address - City:GRETNA
Mailing Address - State:LA
Mailing Address - Zip Code:70056-2558
Mailing Address - Country:US
Mailing Address - Phone:504-362-9010
Mailing Address - Fax:504-362-9070
Practice Address - Street 1:401 WHITNEY AVE
Practice Address - Street 2:STE 409
Practice Address - City:GRETNA
Practice Address - State:LA
Practice Address - Zip Code:70056-2558
Practice Address - Country:US
Practice Address - Phone:504-362-9010
Practice Address - Fax:504-362-9070
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-01-18
Last Update Date:2017-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA5971101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty