Provider Demographics
NPI:1417944992
Name:FOUNTAIN, TINA M (LCSW)
Entity type:Individual
Prefix:
First Name:TINA
Middle Name:M
Last Name:FOUNTAIN
Suffix:
Gender:
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3209 OAKINGTON DR
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:VA
Mailing Address - Zip Code:23231-7267
Mailing Address - Country:US
Mailing Address - Phone:804-677-0379
Mailing Address - Fax:804-351-5972
Practice Address - Street 1:612 HULL ST STE 101A
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:VA
Practice Address - Zip Code:23224-4180
Practice Address - Country:US
Practice Address - Phone:804-351-5971
Practice Address - Fax:804-351-5972
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-30
Last Update Date:2025-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA09040057231041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA010162025Medicaid