Provider Demographics
NPI:1255529434
Name:FOUNTAIN, ERICK (PT)
Entity type:Individual
Prefix:
First Name:ERICK
Middle Name:
Last Name:FOUNTAIN
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21384 PINE CONE DR
Mailing Address - Street 2:
Mailing Address - City:MACOMB
Mailing Address - State:MI
Mailing Address - Zip Code:48042-4335
Mailing Address - Country:US
Mailing Address - Phone:586-949-5334
Mailing Address - Fax:
Practice Address - Street 1:21384 PINE CONE DR
Practice Address - Street 2:
Practice Address - City:MACOMB
Practice Address - State:MI
Practice Address - Zip Code:48042-4335
Practice Address - Country:US
Practice Address - Phone:586-949-5334
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-10-12
Last Update Date:2007-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501010159225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist