Provider Demographics
NPI:1497418297
Name:FULGHAM, SHANNON MARIE (LMFTA)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:MARIE
Last Name:FULGHAM
Suffix:
Gender:F
Credentials:LMFTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12526 FREMONT AVE N
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98133-8048
Mailing Address - Country:US
Mailing Address - Phone:206-915-7386
Mailing Address - Fax:
Practice Address - Street 1:12526 FREMONT AVE N
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98133-8048
Practice Address - Country:US
Practice Address - Phone:206-915-7386
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-10-19
Last Update Date:2021-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMG61220951106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist