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NPI Code Detail

MEDICARE: KRYSTAL MARIE FOUNTAINE

MEDICARE: KRYSTAL MARIE FOUNTAINE
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
1103K00000XBehavior Analyst1-16-23131CA

General Provider Information

NPI Number : 1811131014
Entity Type Code : Individual
Provider Name (Legal Business Name) : KRYSTAL MARIE FOUNTAINE
Provider Business Mailing Address
First Line : 5554 RESEDA BLVD STE 203
Second Line :
City : TARZANA
State : CA
Zip : 91356-6212
Country : US
Telephone Number : 818-698-9507
Fax Number :
Provider Business Practice Location Address
First Line : 5554 RESEDA BLVD STE 203
Second Line :
City : TARZANA
State : CA
Zip : 91356-6212
Country : US
Telephone Number : 818-698-9507
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 05/01/2009
Last Update Date : 01/19/2022

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Directions to “ KRYSTAL MARIE FOUNTAINE ” Practice Location

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