Provider Demographics
NPI:1942025598
Name:TANYA FOUNTAIN LLC
Entity type:Organization
Organization Name:TANYA FOUNTAIN LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINICAL SOCIAL WORKER/ THERAPIST
Authorized Official - Prefix:
Authorized Official - First Name:TANYA
Authorized Official - Middle Name:
Authorized Official - Last Name:FOUNTAIN
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:971-599-3881
Mailing Address - Street 1:780 COMMERCIAL ST SE STE 201
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:OR
Mailing Address - Zip Code:97301-3463
Mailing Address - Country:US
Mailing Address - Phone:971-599-3881
Mailing Address - Fax:503-300-2848
Practice Address - Street 1:780 COMMERCIAL ST SE STE 201
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97301-3463
Practice Address - Country:US
Practice Address - Phone:971-599-3881
Practice Address - Fax:503-300-2848
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-11-19
Last Update Date:2024-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty