Basic Information
| Provider Information | |||||||||
| NPI: | 1962749721 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | FULFORD | ||||||||
| FirstName: | CYNTHIA | ||||||||
| MiddleName: | COLLEEN | ||||||||
| NamePrefix: | MS. | ||||||||
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| Credential: | LSCSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2022 S WEBB RD STE 261 | ||||||||
| Address2: | |||||||||
| City: | WICHITA | ||||||||
| State: | KS | ||||||||
| PostalCode: | 672075627 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3162582409 | ||||||||
| FaxNumber: | 3166343075 | ||||||||
| Practice Location | |||||||||
| Address1: | 9415 E HARRY ST STE 305 | ||||||||
| Address2: | |||||||||
| City: | WICHITA | ||||||||
| State: | KS | ||||||||
| PostalCode: | 672075077 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3162582409 | ||||||||
| FaxNumber: | 3162850527 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/13/2013 | ||||||||
| LastUpdateDate: | 10/02/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 10/02/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | 3767 | KS | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.