Provider Demographics
NPI:1033628805
Name:FULTZ, DWIGHT E (PHD, LP)
Entity Type:Individual
Prefix:
First Name:DWIGHT
Middle Name:E
Last Name:FULTZ
Suffix:
Gender:M
Credentials:PHD, LP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2310 S LAKE IRVING DR SW
Mailing Address - Street 2:
Mailing Address - City:BEMIDJI
Mailing Address - State:MN
Mailing Address - Zip Code:56601-8859
Mailing Address - Country:US
Mailing Address - Phone:218-751-1811
Mailing Address - Fax:
Practice Address - Street 1:1003 HOLLINGER ST
Practice Address - Street 2:
Practice Address - City:PARK RAPIDS
Practice Address - State:MN
Practice Address - Zip Code:56470-1300
Practice Address - Country:US
Practice Address - Phone:218-366-2636
Practice Address - Fax:218-366-2087
Is Sole Proprietor?:Yes
Enumeration Date:2017-09-25
Last Update Date:2017-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLP4277103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNLP4277OtherSTATE OF MINNESOTA - MINNESOTA BOARD OF PSYCHOLOGY