Healthcare Provider Details

I. General information

NPI: 1356052740
Provider Name (Legal Business Name): FOUNTAIN BEHAVIORAL SERVICES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/07/2022
Last Update Date: 12/08/2023
Certification Date: 12/08/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 MAIN ST S
MINOT ND
58701-3914
US

IV. Provider business mailing address

21 MAIN ST S
MINOT ND
58701-3890
US

V. Phone/Fax

Practice location:
  • Phone: 701-839-9363
  • Fax: 855-955-1279
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number State

VIII. Authorized Official

Name: ELISE FELICIO
Title or Position: OWNER
Credential:
Phone: 701-389-9363