MEDICARE: TINA M. FOUNTAIN LCSW

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	1041C0700X	Clinical Social Worker	0904005723	VA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1417944992
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TINA M. FOUNTAIN LCSW

Provider Business Mailing Address
First Line	:	3209 OAKINGTON DR
Second Line	:
City	:	RICHMOND
State	:	VA
Zip	:	23231-7267
Country	:	US
Telephone Number	:	804-677-0379
Fax Number	:	804-351-5972

Provider Business Practice Location Address
First Line	:	612 HULL ST STE 101A
Second Line	:
City	:	RICHMOND
State	:	VA
Zip	:	23224-4180
Country	:	US
Telephone Number	:	804-351-5971
Fax Number	:	804-351-5972

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

Provider Enumeration Date	:	09/30/2005
Last Update Date	:	04/08/2025

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