Provider Demographics
NPI:1447588660
Name:FULTS, KATRINA LYNN (LISW)
Entity Type:Individual
Prefix:
First Name:KATRINA
Middle Name:LYNN
Last Name:FULTS
Suffix:
Gender:F
Credentials:LISW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:716 19TH AVE
Mailing Address - Street 2:
Mailing Address - City:CORALVILLE
Mailing Address - State:IA
Mailing Address - Zip Code:52241-1616
Mailing Address - Country:US
Mailing Address - Phone:319-331-5711
Mailing Address - Fax:
Practice Address - Street 1:5400 KIRKWOOD BLVD SW
Practice Address - Street 2:
Practice Address - City:CEDAR RAPIDS
Practice Address - State:IA
Practice Address - Zip Code:52404-5216
Practice Address - Country:US
Practice Address - Phone:319-364-0259
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-11-29
Last Update Date:2019-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA0072821041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA007282OtherLISW LICENSE
IA007282OtherLMSW LICENSE NUMBER