Basic Information
| Provider Information | |||||||||
| NPI: | 1679083620 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | FULTON | ||||||||
| FirstName: | GENEVIEVE | ||||||||
| MiddleName: | SIMPSON | ||||||||
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| Mailing Information | |||||||||
| Address1: | 13 ETON WAY | ||||||||
| Address2: | |||||||||
| City: | MILL VALLEY | ||||||||
| State: | CA | ||||||||
| PostalCode: | 949411414 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 1 SAINT VINCENTS DR | ||||||||
| Address2: | |||||||||
| City: | SAN RAFAEL | ||||||||
| State: | CA | ||||||||
| PostalCode: | 949031504 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4155072000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/04/2017 | ||||||||
| LastUpdateDate: | 05/26/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 05/26/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 106H00000X | AMFT108487 | CA | Y | Behavioral Health & Social Service Providers | Marriage & Family Therapist | 101YM0800X | N | Behavioral Health & Social Service Providers | Counselor | Mental Health |
No ID Information.