Provider Demographics
NPI:1427619758
Name:FOUNTAIN OF WISDOM AND HOPE LLC
Entity type:Organization
Organization Name:FOUNTAIN OF WISDOM AND HOPE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:ANTOINETTE
Authorized Official - Middle Name:
Authorized Official - Last Name:MALLETT
Authorized Official - Suffix:
Authorized Official - Credentials:LPC
Authorized Official - Phone:517-684-0577
Mailing Address - Street 1:PO BOX 10
Mailing Address - Street 2:
Mailing Address - City:MASON
Mailing Address - State:MI
Mailing Address - Zip Code:48854-0010
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4710 W SAGINAW HWY STE 9
Practice Address - Street 2:
Practice Address - City:LANSING
Practice Address - State:MI
Practice Address - Zip Code:48917-2654
Practice Address - Country:US
Practice Address - Phone:517-615-8312
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-06-26
Last Update Date:2023-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselorGroup - Single Specialty