Provider Demographics
NPI:1003241209
Name:FULCROD, SHANNON NOELLE (LCSW, CSAC, MAC)
Entity Type:Individual
Prefix:MS
First Name:SHANNON
Middle Name:NOELLE
Last Name:FULCROD
Suffix:
Gender:F
Credentials:LCSW, CSAC, MAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 7961
Mailing Address - Street 2:
Mailing Address - City:FREDERICKSBURG
Mailing Address - State:VA
Mailing Address - Zip Code:22404-7961
Mailing Address - Country:US
Mailing Address - Phone:540-760-8985
Mailing Address - Fax:
Practice Address - Street 1:1200 SAM PERRY BLVD
Practice Address - Street 2:
Practice Address - City:FREDERICKSBURG
Practice Address - State:VA
Practice Address - Zip Code:22401-4456
Practice Address - Country:US
Practice Address - Phone:540-760-8985
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-09-06
Last Update Date:2013-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0710102773101YA0400X
VA09040071031041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)