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KELLY FOUNTAIN, M.S., L.P.T., L.L.C.

Details

Name: KELLY FOUNTAIN, M.S., L.P.T., L.L.C.
Jurisdiction: Alabama
Legal type: Domestic Limited Liability Company
Status: Exists
Date of registration: 30 Jan 2013 (12 years ago) (Companies founded in January 2013)
Entity Number: 000-273-531
Register Number: 000273531
ZIP code: 36606 (Companies in Mobile, 36606)
County: Mobile
Place of Formation: Mobile County
Principal Address: 2864 DAUPHIN STREET SUITE AMOBILE, AL 36606

Activities PHYCHOLOGICAL SERVICES

National Provider Identifier

NPI Enumeration Date Last Update Date Mailing Address Practice Location Address
1154714384 2015-03-12 2015-03-12 2864 DAUPHIN ST, SUITE A, MOBILE, AL, 366062479, US 2864 DAUPHIN ST, SUITE A, MOBILE, AL, 366062479, US

Contacts

Phone +1 251-470-7607

Authorized person

Name KELLY FOUNTAIN
Role OWNER
Phone 2514707607

Taxonomy

Taxonomy Code 101Y00000X - Counselor
License Number 1586
State AL
Is Primary Yes

Other Provider Identifiers

Issuer NPI
Number 1003148487
State AL
Issuer BLUE CROSS BLUE SHIELD
Number 511-33704
State AL

Agent

Name Role Address
FOUNTAIN, KELLY Agent 2864 DAUPHIN STREET SUITE AMOBILE, AL 36606

Organizer

Name Role Address
FOUNTAIN, KELLY Organizer 2864 DAUPHIN STREET SUITE AMOBILE, AL 36606

Date of last update: 02 Aug 2024

Sources: Alabama Secretary of State