Provider Demographics
NPI:1154725315
Name:FULTON, FRED IV
Entity type:Individual
Prefix:MR
First Name:FRED
Middle Name:
Last Name:FULTON
Suffix:IV
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 1:109 LARCHE DR
Mailing Address - Street 2:
Mailing Address - City:WEST MONROE
Mailing Address - State:LA
Mailing Address - Zip Code:71291-5401
Mailing Address - Country:US
Mailing Address - Phone:318-651-9626
Mailing Address - Fax:
Practice Address - Street 1:501 BROADWAY ST
Practice Address - Street 2:
Practice Address - City:DELHI
Practice Address - State:LA
Practice Address - Zip Code:71232-3001
Practice Address - Country:US
Practice Address - Phone:318-878-8658
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-10-17
Last Update Date:2021-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YP1600XBehavioral Health & Social Service ProvidersCounselorPastoral