Provider Demographics
NPI:1073900544
Name:FULTON, TARA (LCSW)
Entity Type:Individual
Prefix:MS
First Name:TARA
Middle Name:
Last Name:FULTON
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 1:707 CORINNE ST
Mailing Address - Street 2:
Mailing Address - City:HATTIESBURG
Mailing Address - State:MS
Mailing Address - Zip Code:39401-3854
Mailing Address - Country:US
Mailing Address - Phone:601-408-6284
Mailing Address - Fax:
Practice Address - Street 1:707 CORINNE ST
Practice Address - Street 2:
Practice Address - City:HATTIESBURG
Practice Address - State:MS
Practice Address - Zip Code:39401-3854
Practice Address - Country:US
Practice Address - Phone:601-408-6284
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-04-22
Last Update Date:2015-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSC74331041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MSMMLGN5758XMedicaid