Basic Information
Provider Information | |||||||||
NPI: | 1265864821 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | FULTON | ||||||||
FirstName: | ANDY | ||||||||
MiddleName: | LEROY | ||||||||
NamePrefix: | MR. | ||||||||
NameSuffix: | JR. | ||||||||
Credential: | RAS | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1901 CLEVELAND AVENUE #B | ||||||||
Address2: | SANTA ROSA TREATMENT PROGRAM | ||||||||
City: | SANTA ROSA | ||||||||
State: | CA | ||||||||
PostalCode: | 95401 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7075760818 | ||||||||
FaxNumber: | 7075767845 | ||||||||
Practice Location | |||||||||
Address1: | 1901 CLEVELAND AVENUE, #B | ||||||||
Address2: |   | ||||||||
City: | SANTA ROSA | ||||||||
State: | CA | ||||||||
PostalCode: | 95401 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7075760818 | ||||||||
FaxNumber: | 7075767845 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 08/06/2013 | ||||||||
LastUpdateDate: | 08/06/2013 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | F1101261615 | CA | Y |   | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
No ID Information.