Provider Demographics
NPI:1316782287
Name:FULMER, SHALON
Entity type:Individual
Prefix:
First Name:SHALON
Middle Name:
Last Name:FULMER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2715 E RUSSELL RD
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89120-2426
Mailing Address - Country:US
Mailing Address - Phone:725-238-4115
Mailing Address - Fax:
Practice Address - Street 1:2715 E RUSSELL RD
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89120-2426
Practice Address - Country:US
Practice Address - Phone:725-238-4115
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-07-01
Last Update Date:2024-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVRBT-24-357446106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician