Provider Demographics
NPI:1376398867
Name:FULTZ, GRACE
Entity Type:Individual
Prefix:
First Name:GRACE
Middle Name:
Last Name:FULTZ
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:127 S BENTZ ST
Mailing Address - Street 2:
Mailing Address - City:FREDERICK
Mailing Address - State:MD
Mailing Address - Zip Code:21701-5507
Mailing Address - Country:US
Mailing Address - Phone:937-369-1120
Mailing Address - Fax:
Practice Address - Street 1:3510 WORTHINGTON BLVD UNIT 101
Practice Address - Street 2:
Practice Address - City:URBANA
Practice Address - State:MD
Practice Address - Zip Code:21704-7066
Practice Address - Country:US
Practice Address - Phone:240-883-6847
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-04-18
Last Update Date:2024-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDLGM1032106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist