Provider Demographics
NPI:1164763579
Name:FULLERTON, NICOLE RENEE (MSW, CSW)
Entity Type:Individual
Prefix:MRS
First Name:NICOLE
Middle Name:RENEE
Last Name:FULLERTON
Suffix:
Gender:F
Credentials:MSW, CSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2252 PINYON JAY DR
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80951-4707
Mailing Address - Country:US
Mailing Address - Phone:502-741-6655
Mailing Address - Fax:
Practice Address - Street 1:25 N SPRUCE ST
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80905-1436
Practice Address - Country:US
Practice Address - Phone:719-227-4207
Practice Address - Fax:719-227-4001
Is Sole Proprietor?:No
Enumeration Date:2013-03-11
Last Update Date:2014-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY6986104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker