=====================================================
General NPI Number Information
=====================================================
NPI Number | 1154714384
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | KELLY FOUNTAIN, M.S., L.P.T., L.L.C.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/12/2015
-----------------------------------------------------
Last Update Date | 03/12/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2864 DAUPHIN ST SUITE A
-----------------------------------------------------
City | MOBILE
-----------------------------------------------------
State | AL
-----------------------------------------------------
Zip | 36606-2479
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 251-470-7607
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2864 DAUPHIN ST SUITE A
-----------------------------------------------------
City | MOBILE
-----------------------------------------------------
State | AL
-----------------------------------------------------
Zip | 36606-2479
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | KELLY FOUNTAIN
-----------------------------------------------------
Credential | MS, LPT
-----------------------------------------------------
Telephone | 251-470-7607
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101Y00000X
-----------------------------------------------------
Taxonomy Name | Counselor
-----------------------------------------------------
License Number | 1586
-----------------------------------------------------
License Number State | AL
-----------------------------------------------------