Provider Demographics
NPI:1104250075
Name:FULKS, LAVELL
Entity type:Individual
Prefix:
First Name:LAVELL
Middle Name:
Last Name:FULKS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10 ORLANDO ST
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02126-1700
Mailing Address - Country:US
Mailing Address - Phone:617-516-7689
Mailing Address - Fax:
Practice Address - Street 1:317 BLUE HILL AVE
Practice Address - Street 2:
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02121-4302
Practice Address - Country:US
Practice Address - Phone:617-989-0292
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-08-28
Last Update Date:2013-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor