Provider Demographics
NPI:1417514274
Name:CARDINAL CLINICAL CONSULTING, LLC
Entity Type:Organization
Organization Name:CARDINAL CLINICAL CONSULTING, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:JOSHUA
Authorized Official - Middle Name:C
Authorized Official - Last Name:FULWILER
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:662-269-3599
Mailing Address - Street 1:2625 TRACELAND DR STE B
Mailing Address - Street 2:
Mailing Address - City:TUPELO
Mailing Address - State:MS
Mailing Address - Zip Code:38801-4240
Mailing Address - Country:US
Mailing Address - Phone:662-269-3599
Mailing Address - Fax:662-259-2503
Practice Address - Street 1:2625 TRACELAND DR STE B
Practice Address - Street 2:
Practice Address - City:TUPELO
Practice Address - State:MS
Practice Address - Zip Code:38801-4240
Practice Address - Country:US
Practice Address - Phone:662-269-3599
Practice Address - Fax:662-259-2503
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-05-28
Last Update Date:2019-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty