Healthcare Provider Details

I. General information

NPI: 1720958085
Provider Name (Legal Business Name): FOUNTAIN WELLNESS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/10/2025
Last Update Date: 11/10/2025
Certification Date: 11/10/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3030 S COLLEGE AVE
FORT COLLINS CO
80525-2557
US

IV. Provider business mailing address

2762 CENTER PARK WAY
BERTHOUD CO
80513-2712
US

V. Phone/Fax

Practice location:
  • Phone: 720-310-8731
  • Fax:
Mailing address:
  • Phone: 720-310-8731
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name: NICOLE BLEAU
Title or Position: OWNER
Credential:
Phone: 720-310-8731