Provider Demographics
NPI:1235464504
Name:FULTON, DENNA MARIE (LCSW, QMHP, CADCIII)
Entity Type:Individual
Prefix:
First Name:DENNA
Middle Name:MARIE
Last Name:FULTON
Suffix:
Gender:F
Credentials:LCSW, QMHP, CADCIII
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2073 OLYMPIC ST
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:OR
Mailing Address - Zip Code:97477-3413
Mailing Address - Country:US
Mailing Address - Phone:541-682-3550
Mailing Address - Fax:541-682-3551
Practice Address - Street 1:2073 OLYMPIC ST
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:OR
Practice Address - Zip Code:97477
Practice Address - Country:US
Practice Address - Phone:541-682-3550
Practice Address - Fax:541-682-3551
Is Sole Proprietor?:No
Enumeration Date:2009-10-05
Last Update Date:2020-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR1309-50101YA0400X
101YM0800X
ORL80321041C0700X
ORTHW0621175T00000X, 175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No175T00000XOther Service ProvidersPeer Specialist