Provider Demographics
NPI:1205409992
Name:FULP, CHARLY (LCMHC-A)
Entity Type:Individual
Prefix:
First Name:CHARLY
Middle Name:
Last Name:FULP
Suffix:
Gender:F
Credentials:LCMHC-A
Other - Prefix:
Other - First Name:CHARLY
Other - Middle Name:
Other - Last Name:SMITH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1240 SE MAYNARD RD
Mailing Address - Street 2:
Mailing Address - City:CARY
Mailing Address - State:NC
Mailing Address - Zip Code:27511-6929
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1240 SE MAYNARD RD
Practice Address - Street 2:
Practice Address - City:CARY
Practice Address - State:NC
Practice Address - Zip Code:27511-6929
Practice Address - Country:US
Practice Address - Phone:919-636-0762
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-07-20
Last Update Date:2021-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCA16790103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist