Provider Demographics
NPI:1699099846
Name:MYERS, CAROL FULLERTON (LPC)
Entity type:Individual
Prefix:
First Name:CAROL
Middle Name:FULLERTON
Last Name:MYERS
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:972 PICO PT
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80905-7380
Mailing Address - Country:US
Mailing Address - Phone:719-640-7630
Mailing Address - Fax:
Practice Address - Street 1:972 PICO PT
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80905-7380
Practice Address - Country:US
Practice Address - Phone:719-640-7630
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-03-17
Last Update Date:2010-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO4259101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO11831642OtherCAQH