Basic Information
| Provider Information | |||||||||
| NPI: | 1871965343 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | FULGHAM | ||||||||
| FirstName: | CAROLYN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 330 N GORE AVE | ||||||||
| Address2: | |||||||||
| City: | SAINT LOUIS | ||||||||
| State: | MO | ||||||||
| PostalCode: | 631191600 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3149682060 | ||||||||
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| Practice Location | |||||||||
| Address1: | 5471 DR MARTIN LUTHER KING DR | ||||||||
| Address2: | |||||||||
| City: | SAINT LOUIS | ||||||||
| State: | MO | ||||||||
| PostalCode: | 631124265 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3143675820 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/23/2015 | ||||||||
| LastUpdateDate: | 11/03/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 11/03/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 104100000X | 2015029538 | MO | N | Behavioral Health & Social Service Providers | Social Worker | 1041C0700X | 2020021039 | MO | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.