Provider Demographics
NPI:1366744518
Name:FULCHER, REBECCA MARIE-ROSE (MA, BCBA)
Entity type:Individual
Prefix:MRS
First Name:REBECCA
Middle Name:MARIE-ROSE
Last Name:FULCHER
Suffix:
Gender:F
Credentials:MA, BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:670 CHADINGS DR
Mailing Address - Street 2:
Mailing Address - City:ROANOKE
Mailing Address - State:IN
Mailing Address - Zip Code:46783-8875
Mailing Address - Country:US
Mailing Address - Phone:423-582-9494
Mailing Address - Fax:
Practice Address - Street 1:7230 ENGLE RD STE 102
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46804-2234
Practice Address - Country:US
Practice Address - Phone:260-373-1050
Practice Address - Fax:260-471-0285
Is Sole Proprietor?:Yes
Enumeration Date:2010-11-20
Last Update Date:2019-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1107501103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst