Provider Demographics
NPI:1114723244
Name:FULFORD, MADISON ROSE (LCMHC-A)
Entity type:Individual
Prefix:
First Name:MADISON
Middle Name:ROSE
Last Name:FULFORD
Suffix:
Gender:
Credentials:LCMHC-A
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4180 DUDLEYS GRANT DR APT B
Mailing Address - Street 2:
Mailing Address - City:WINTERVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28590-8350
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:620 LYNNDALE CT STE C
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:NC
Practice Address - Zip Code:27858-5462
Practice Address - Country:US
Practice Address - Phone:252-752-8602
Practice Address - Fax:252-752-8103
Is Sole Proprietor?:No
Enumeration Date:2025-02-20
Last Update Date:2025-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCA21108101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health