MEDICARE: MS. SHEPHERD MACDOUGALD FOUNTAIN LCSW LCAS

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	101YA0400X	Addiction (Substance Use Disorder) Counselor	648LCAS	NC
2	1041C0700X	Clinical Social Worker	C003525LCSW	NC

General Provider Information

NPI Number	:	1871632729
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. SHEPHERD MACDOUGALD FOUNTAIN LCSW LCAS

Provider Business Mailing Address
First Line	:	111 EDENBURGH RD
Second Line	:
City	:	RALEIGH
State	:	NC
Zip	:	27608
Country	:	US
Telephone Number	:	919-788-8002
Fax Number	:	919-788-0740

Provider Business Practice Location Address
First Line	:	4010 BARRETT DR
Second Line	:	STE 101
City	:	RALEIGH
State	:	NC
Zip	:	27609
Country	:	US
Telephone Number	:	919-788-8002
Fax Number	:	919-788-0740

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

Provider Enumeration Date	:	02/06/2007
Last Update Date	:	01/16/2009

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