Provider Demographics
NPI:1427300466
Name:FOUNTAIN, TINA MARCELLE
Entity type:Individual
Prefix:DR
First Name:TINA
Middle Name:MARCELLE
Last Name:FOUNTAIN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:85 ABIGAIL LN
Mailing Address - Street 2:
Mailing Address - City:MAGNOLIA
Mailing Address - State:DE
Mailing Address - Zip Code:19962-3251
Mailing Address - Country:US
Mailing Address - Phone:443-477-2156
Mailing Address - Fax:
Practice Address - Street 1:1131 AIRPORT RD
Practice Address - Street 2:
Practice Address - City:MILFORD
Practice Address - State:DE
Practice Address - Zip Code:19963-6418
Practice Address - Country:US
Practice Address - Phone:443-477-2156
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-10-15
Last Update Date:2013-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEB1-0000807103T00000X
NY018018-1103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist