Basic Information
| Provider Information | |||||||||
| NPI: | 1154714384 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | KELLY FOUNTAIN, M.S., L.P.T., L.L.C. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2864 DAUPHIN ST | ||||||||
| Address2: | SUITE A | ||||||||
| City: | MOBILE | ||||||||
| State: | AL | ||||||||
| PostalCode: | 366062479 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 2864 DAUPHIN ST | ||||||||
| Address2: | SUITE A | ||||||||
| City: | MOBILE | ||||||||
| State: | AL | ||||||||
| PostalCode: | 366062479 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2514707607 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/12/2015 | ||||||||
| LastUpdateDate: | 03/12/2015 | ||||||||
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| AuthorizedOfficialLastName: | FOUNTAIN | ||||||||
| AuthorizedOfficialFirstName: | KELLY | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 2514707607 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MS, LPT | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101Y00000X | 1586 | AL | Y | 193400000X SINGLE SPECIALTY GROUP | Behavioral Health & Social Service Providers | Counselor |
ID Information
| ID | Type | State | Issuer | Description | 1003148487 | 01 | AL | NPI | OTHER | 511-33704 | 01 | AL | BLUE CROSS BLUE SHIELD | OTHER |