Provider Demographics
NPI:1164693172
Name:FULTZ, LARRY ELMER (PHD)
Entity Type:Individual
Prefix:DR
First Name:LARRY
Middle Name:ELMER
Last Name:FULTZ
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:407 ALABAMA RD
Mailing Address - Street 2:
Mailing Address - City:TOWSON
Mailing Address - State:MD
Mailing Address - Zip Code:21204-4308
Mailing Address - Country:US
Mailing Address - Phone:410-823-1429
Mailing Address - Fax:
Practice Address - Street 1:5024 CAMPBELL BLVD
Practice Address - Street 2:SUITE H
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21236
Practice Address - Country:US
Practice Address - Phone:410-931-9280
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-03-18
Last Update Date:2008-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD062481041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical