Provider Demographics
NPI:1174636641
Name:FULFORD, LAURIE MARIE (LCSW)
Entity Type:Individual
Prefix:
First Name:LAURIE
Middle Name:MARIE
Last Name:FULFORD
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 1:308 FORTY OAKS FARM RD
Mailing Address - Street 2:
Mailing Address - City:WEST MONROE
Mailing Address - State:LA
Mailing Address - Zip Code:71291-9095
Mailing Address - Country:US
Mailing Address - Phone:318-397-7084
Mailing Address - Fax:
Practice Address - Street 1:250 DESIARD PLAZA DR
Practice Address - Street 2:
Practice Address - City:MONROE
Practice Address - State:LA
Practice Address - Zip Code:71203-4955
Practice Address - Country:US
Practice Address - Phone:318-343-6100
Practice Address - Fax:318-343-8600
Is Sole Proprietor?:No
Enumeration Date:2006-08-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA72831041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical