Basic Information
| Provider Information | |||||||||
| NPI: | 1629176334 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | FULTON | ||||||||
| FirstName: | JUNE | ||||||||
| MiddleName: | E | ||||||||
| NamePrefix: | MS. | ||||||||
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| Credential: | MSW LCSW PHD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 12700 HILLCREST RD | ||||||||
| Address2: | 176 | ||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 752302033 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9722331010 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 12700 HILLCREST RD | ||||||||
| Address2: | 176 | ||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 752302033 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9722331010 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 09/20/2006 | ||||||||
| LastUpdateDate: | 02/20/2009 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | 52435 | TX | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical | 1041C0700X | 149004072 | IL | N | Behavioral Health & Social Service Providers | Social Worker | Clinical |
ID Information
| ID | Type | State | Issuer | Description | 0001634861 | 01 | IL | BLUE CROSS BLUE SHIELD | OTHER |