Basic Information
| Provider Information | |||||||||
| NPI: | 1407501364 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | FOUNTAINGATE WELLNESS PLLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1106 COLUMBIA AVE STE 100 | ||||||||
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| City: | MARYSVILLE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 982704311 | ||||||||
| CountryCode: | US | ||||||||
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| Address1: | 1106 COLUMBIA AVE STE 100 | ||||||||
| Address2: | |||||||||
| City: | MARYSVILLE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 982704311 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3606530374 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 02/18/2022 | ||||||||
| LastUpdateDate: | 02/18/2022 | ||||||||
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| AuthorizedOfficialLastName: | WYKES | ||||||||
| AuthorizedOfficialFirstName: | SCOTT | ||||||||
| AuthorizedOfficialMiddleName: | D | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 3606530374 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 02/18/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | Y | 193400000X SINGLE SPECIALTY GROUP | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
No ID Information.