Provider Demographics
NPI:1063462752
Name:FULTZ, LARKIN ELLISON (LCSW)
Entity Type:Individual
Prefix:
First Name:LARKIN
Middle Name:ELLISON
Last Name:FULTZ
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:204 EAST 6TH AVENUE
Mailing Address - Street 2:
Mailing Address - City:COVINGTON
Mailing Address - State:LA
Mailing Address - Zip Code:70433
Mailing Address - Country:US
Mailing Address - Phone:985-264-1683
Mailing Address - Fax:985-892-2287
Practice Address - Street 1:4038 DESOTO STREET
Practice Address - Street 2:
Practice Address - City:MANDEVILLE
Practice Address - State:LA
Practice Address - Zip Code:70471
Practice Address - Country:US
Practice Address - Phone:985-264-1683
Practice Address - Fax:985-892-2287
Is Sole Proprietor?:No
Enumeration Date:2006-05-11
Last Update Date:2016-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA40301041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA4B506Medicare ID - Type Unspecified