Provider Demographics
NPI:1871201152
Name:FONTAINE, BRIAN H (CADAC II)
Entity type:Individual
Prefix:
First Name:BRIAN
Middle Name:H
Last Name:FONTAINE
Suffix:
Gender:M
Credentials:CADAC II
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2125 E 450 S
Mailing Address - Street 2:
Mailing Address - City:LA PORTE
Mailing Address - State:IN
Mailing Address - Zip Code:46350-7649
Mailing Address - Country:US
Mailing Address - Phone:192-608-4926
Mailing Address - Fax:
Practice Address - Street 1:2125 E 450 S
Practice Address - Street 2:
Practice Address - City:LA PORTE
Practice Address - State:IN
Practice Address - Zip Code:46350-7649
Practice Address - Country:US
Practice Address - Phone:192-608-4926
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-11-07
Last Update Date:2022-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
INC2-5180103TA0400X, 106S00000X, 101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No103TA0400XBehavioral Health & Social Service ProvidersPsychologistAddiction (Substance Use Disorder)
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician