Provider Demographics
NPI:1316064132
Name:FULCHER, MICHELLE RENEE LARKIN (ACSW, LMSW)
Entity type:Individual
Prefix:MS
First Name:MICHELLE
Middle Name:RENEE LARKIN
Last Name:FULCHER
Suffix:
Gender:F
Credentials:ACSW, LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:142 E MAUMEE ST
Mailing Address - Street 2:STE. 6
Mailing Address - City:ADRIAN
Mailing Address - State:MI
Mailing Address - Zip Code:49221-2735
Mailing Address - Country:US
Mailing Address - Phone:734-576-5465
Mailing Address - Fax:517-417-1718
Practice Address - Street 1:142 E MAUMEE ST
Practice Address - Street 2:STE. 6
Practice Address - City:ADRIAN
Practice Address - State:MI
Practice Address - Zip Code:49221-2735
Practice Address - Country:US
Practice Address - Phone:734-576-5465
Practice Address - Fax:517-417-1718
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-25
Last Update Date:2015-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68010850461041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI825220000OtherMAGELLAN
MI0P22950Medicare PIN
MI0P22950Medicare ID - Type UnspecifiedWPS MEDICARE PART B