=====================================================
General NPI Number Information
=====================================================
NPI Number | 1730065749
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | RHONDA FOUNTAIN MS, LIAC
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/14/2025
-----------------------------------------------------
Last Update Date | 08/14/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2500 E SHOW LOW LAKE RD
-----------------------------------------------------
City | SHOW LOW
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85901-7994
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 928-892-5870
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2500 E SHOW LOW LAKE RD
-----------------------------------------------------
City | SHOW LOW
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85901-7994
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YA0400X
-----------------------------------------------------
Taxonomy Name | Addiction (Substance Use Disorder) Counselor
-----------------------------------------------------
License Number | LIAC-155349
-----------------------------------------------------
License Number State | AZ
-----------------------------------------------------