Provider Demographics
NPI:1407464688
Name:FULTON-DELONG, BROOK ALEXIS (LCPC, NCC)
Entity Type:Individual
Prefix:
First Name:BROOK
Middle Name:ALEXIS
Last Name:FULTON-DELONG
Suffix:
Gender:F
Credentials:LCPC, NCC
Other - Prefix:
Other - First Name:BROOK
Other - Middle Name:ALEXIS
Other - Last Name:FULTON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:8181 MAIN ST APT 2
Mailing Address - Street 2:
Mailing Address - City:ELLICOTT CITY
Mailing Address - State:MD
Mailing Address - Zip Code:21043-4929
Mailing Address - Country:US
Mailing Address - Phone:410-505-0062
Mailing Address - Fax:
Practice Address - Street 1:8181 MAIN ST APT 2
Practice Address - Street 2:
Practice Address - City:ELLICOTT CITY
Practice Address - State:MD
Practice Address - Zip Code:21043-4929
Practice Address - Country:US
Practice Address - Phone:757-651-3001
Practice Address - Fax:757-222-3833
Is Sole Proprietor?:No
Enumeration Date:2020-07-14
Last Update Date:2022-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDLGP10581101YM0800X
MDLC12594101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health