Basic Information
| Provider Information | |||||||||
| NPI: | 1689914376 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | FULTZ | ||||||||
| FirstName: | DENISE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 7455 SW BEVELAND RD | ||||||||
| Address2: | |||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972238610 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5036242600 | ||||||||
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| Practice Location | |||||||||
| Address1: | 7455 SW BEVELAND RD | ||||||||
| Address2: | |||||||||
| City: | TIGARD | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972238610 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5032335405 | ||||||||
| FaxNumber: | 5032332694 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/18/2013 | ||||||||
| LastUpdateDate: | 02/18/2013 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103K00000X | Y | Behavioral Health & Social Service Providers | Behavioral Analyst |
ID Information
| ID | Type | State | Issuer | Description | 164936 | 01 | OR | MEDICARE GROUP | OTHER |