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General NPI Number Information
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NPI Number | 1316320807
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Entity Type | Individual
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Provider Name | CONRAD FOUNTAINE LCSW
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Gender | Male
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Dates
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Enumeration Date | 07/02/2015
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Last Update Date | 07/02/2015
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Provider Practice Location Address
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Address Line | 1930 MARLTON PIKE E STE R91
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City | CHERRY HILL
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State | NJ
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Zip | 08003-4207
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Country | US
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Telephone | 856-816-7114
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Fax | 856-751-0505
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Provider Business Mailing Address
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Address Line | 1930 MARLTON PIKE E STE R91
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City | CHERRY HILL
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State | NJ
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Zip | 08003-4207
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Country | US
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Telephone | 856-816-7114
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Fax | 856-751-0505
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1041C0700X
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Taxonomy Name | Clinical Social Worker
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License Number | 44SC00746700
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License Number State | NJ
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