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General NPI Number Information
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NPI Number | 1427300466
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Entity Type | Individual
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Provider Name | DR. TINA MARCELLE FOUNTAIN
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Gender | Female
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Dates
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Enumeration Date | 10/15/2012
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Last Update Date | 04/19/2013
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Provider Practice Location Address
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Address Line | 1131 AIRPORT RD
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City | MILFORD
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State | DE
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Zip | 19963-6418
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Country | US
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Telephone | 443-477-2156
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Fax |
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Provider Business Mailing Address
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Address Line | 85 ABIGAIL LN
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City | MAGNOLIA
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State | DE
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Zip | 19962-3251
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Country | US
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Telephone | 443-477-2156
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Fax |
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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 | 103T00000X
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Taxonomy Name | Psychologist
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License Number | B1-0000807
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License Number State | DE
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Taxonomy #2
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Taxonomy Code | 103T00000X
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Taxonomy Name | Psychologist
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License Number | 018018-1
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License Number State | NY
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