Provider Demographics
NPI:1033407218
Name:FULCHER, CAROLYN DIANA (LCSW)
Entity Type:Individual
Prefix:
First Name:CAROLYN
Middle Name:DIANA
Last Name:FULCHER
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:CAROLYN
Other - Middle Name:DIANA
Other - Last Name:KING
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LCSW
Mailing Address - Street 1:300 N MCCOMBS ST STE 1
Mailing Address - Street 2:
Mailing Address - City:MARTIN
Mailing Address - State:TN
Mailing Address - Zip Code:38237-2165
Mailing Address - Country:US
Mailing Address - Phone:731-281-8070
Mailing Address - Fax:731-281-8070
Practice Address - Street 1:300 N MCCOMBS ST STE 1
Practice Address - Street 2:
Practice Address - City:MARTIN
Practice Address - State:TN
Practice Address - Zip Code:38237-2165
Practice Address - Country:US
Practice Address - Phone:731-587-4438
Practice Address - Fax:731-681-4111
Is Sole Proprietor?:No
Enumeration Date:2011-07-21
Last Update Date:2024-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN61931041C0700X, 1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNQ015002Medicaid