Provider Demographics
NPI:1437493582
Name:FULTON, MELISSA J
Entity Type:Individual
Prefix:MRS
First Name:MELISSA
Middle Name:J
Last Name:FULTON
Suffix:
Gender:F
Credentials:
Other - Prefix:MS
Other - First Name:MELISSA
Other - Middle Name:MICHOLE
Other - Last Name:JONES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:128 E MILL ST STE A
Mailing Address - Street 2:
Mailing Address - City:KINGSTREE
Mailing Address - State:SC
Mailing Address - Zip Code:29556-3428
Mailing Address - Country:US
Mailing Address - Phone:843-401-9217
Mailing Address - Fax:843-354-6461
Practice Address - Street 1:128 E MILL ST STE A
Practice Address - Street 2:
Practice Address - City:KINGSTREE
Practice Address - State:SC
Practice Address - Zip Code:29556-3428
Practice Address - Country:US
Practice Address - Phone:843-401-9217
Practice Address - Fax:843-354-6461
Is Sole Proprietor?:No
Enumeration Date:2012-11-15
Last Update Date:2016-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
SC6219101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCPC1606Medicaid
SC3338Medicare UPIN