Provider Demographics
NPI:1699171728
Name:GREEN-FULFORD, VERNIECE
Entity type:Individual
Prefix:
First Name:VERNIECE
Middle Name:
Last Name:GREEN-FULFORD
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 1:2744 HYLAN BLVD # 116
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10306-4658
Mailing Address - Country:US
Mailing Address - Phone:929-333-6905
Mailing Address - Fax:929-566-8627
Practice Address - Street 1:360 NEW DORP LN STE C
Practice Address - Street 2:
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10306-3035
Practice Address - Country:US
Practice Address - Phone:929-333-6905
Practice Address - Fax:929-566-8627
Is Sole Proprietor?:Yes
Enumeration Date:2014-11-18
Last Update Date:2022-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY010838101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health