MEDICARE: BRANDY THELMA FOUNTAIN LPCC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YM0800X	Mental Health Counselor

General Provider Information

NPI Number	:	1457809139
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	BRANDY THELMA FOUNTAIN LPCC

Provider Business Mailing Address
First Line	:	2823 LEXINGTON AVE N
Second Line	:	APT 103
City	:	ROSEVILLE
State	:	MN
Zip	:	55113-2086
Country	:	US
Telephone Number	:	612-275-3985
Fax Number	:

Provider Business Practice Location Address
First Line	:	2823 LEXINGTON AVE N
Second Line	:	APT 103
City	:	ROSEVILLE
State	:	MN
Zip	:	55113-2086
Country	:	US
Telephone Number	:	612-275-3985
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/12/2016
Last Update Date	:	07/22/2024

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