MEDICARE: CARLETTA FOUNTAIN

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101Y00000X	Counselor

General Provider Information

NPI Number	:	1215130398
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CARLETTA FOUNTAIN

Provider Business Mailing Address
First Line	:	168 GOODRICH ST
Second Line	:
City	:	HAMDEN
State	:	CT
Zip	:	06517-3204
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	226 DIXWELL AVE
Second Line	:
City	:	NEW HAVEN
State	:	CT
Zip	:	06511-3456
Country	:	US
Telephone Number	:	203-503-3470
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/07/2007
Last Update Date	:	07/08/2007

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Directions to “ CARLETTA FOUNTAIN ” Practice Location

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