Provider Demographics
NPI:1356620066
Name:FOUNTAIN, MISTY VANLANDINGHAM (CCC-SLP)
Entity type:Individual
Prefix:MRS
First Name:MISTY
Middle Name:VANLANDINGHAM
Last Name:FOUNTAIN
Suffix:
Gender:F
Credentials:CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5891 BUCKNER CREEK DR
Mailing Address - Street 2:
Mailing Address - City:MABLETON
Mailing Address - State:GA
Mailing Address - Zip Code:30126-2795
Mailing Address - Country:US
Mailing Address - Phone:404-281-4126
Mailing Address - Fax:
Practice Address - Street 1:1685 HARLINGTON RD
Practice Address - Street 2:
Practice Address - City:SMYRNA
Practice Address - State:GA
Practice Address - Zip Code:30082-5052
Practice Address - Country:US
Practice Address - Phone:770-432-0395
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-08-11
Last Update Date:2011-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GASLP005004235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist