Healthcare Provider Details

I. General information

NPI: 1457726036
Provider Name (Legal Business Name): LAURA FONTAINE MS, EDS, LISAC, LPC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/07/2015
Last Update Date: 06/18/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2345 S ALMA SCHOOL RD STE 105
MESA AZ
85210-4013
US

IV. Provider business mailing address

18445 E PINE VALLEY DR
QUEEN CREEK AZ
85142-3622
US

V. Phone/Fax

Practice location:
  • Phone: 480-206-4753
  • Fax:
Mailing address:
  • Phone: 480-206-4753
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberLISAC-10622
License Number StateAZ
# 2
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberLPC-15936
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: