Provider Demographics
NPI:1285634691
Name:FULTZ, JOSEPHINE ANN (LP)
Entity Type:Individual
Prefix:MRS
First Name:JOSEPHINE
Middle Name:ANN
Last Name:FULTZ
Suffix:
Gender:F
Credentials:LP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:403 4TH ST NW
Mailing Address - Street 2:P.O. BOX 741
Mailing Address - City:BEMIDJI
Mailing Address - State:MN
Mailing Address - Zip Code:56601-3155
Mailing Address - Country:US
Mailing Address - Phone:218-751-1987
Mailing Address - Fax:
Practice Address - Street 1:403 4TH ST NW
Practice Address - Street 2:SUITE 110
Practice Address - City:BEMIDJI
Practice Address - State:MN
Practice Address - Zip Code:56601-3142
Practice Address - Country:US
Practice Address - Phone:218-751-1987
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-07-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLP2849103TC1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling