Provider Demographics
NPI:1750535787
Name:BILL FULTON LCSW PC
Entity type:Organization
Organization Name:BILL FULTON LCSW PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILL FULTON LCSW PC
Authorized Official - Prefix:MR
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:JOHN
Authorized Official - Last Name:FULTON
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:801-278-2298
Mailing Address - Street 1:2290 E 4500 S
Mailing Address - Street 2:SUITE 230
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84117-4492
Mailing Address - Country:US
Mailing Address - Phone:801-278-2298
Mailing Address - Fax:
Practice Address - Street 1:2290 E 4500 S
Practice Address - Street 2:SUITE 230
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84117-4492
Practice Address - Country:US
Practice Address - Phone:801-278-2298
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-11-04
Last Update Date:2008-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT88-135506-35011041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT000077063Medicare PIN