Provider Demographics
NPI:1073979662
Name:FULLINGTON, LAUREL ANN (MA)
Entity Type:Individual
Prefix:MS
First Name:LAUREL
Middle Name:ANN
Last Name:FULLINGTON
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:630 SW 149TH ST
Mailing Address - Street 2:SUITE 101
Mailing Address - City:BURIEN
Mailing Address - State:WA
Mailing Address - Zip Code:98166-1901
Mailing Address - Country:US
Mailing Address - Phone:206-612-0665
Mailing Address - Fax:206-244-0253
Practice Address - Street 1:630 SW 149TH ST
Practice Address - Street 2:SUITE 101
Practice Address - City:BURIEN
Practice Address - State:WA
Practice Address - Zip Code:98166-1901
Practice Address - Country:US
Practice Address - Phone:206-612-0665
Practice Address - Fax:206-244-0253
Is Sole Proprietor?:Yes
Enumeration Date:2016-01-12
Last Update Date:2016-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WALH60544439251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health