Provider Demographics
NPI:1497718399
Name:FULGHAM, DOROTHY MICHELE (OT)
Entity Type:Individual
Prefix:MRS
First Name:DOROTHY
Middle Name:MICHELE
Last Name:FULGHAM
Suffix:
Gender:F
Credentials:OT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 23996
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39225-3996
Mailing Address - Country:US
Mailing Address - Phone:601-206-6100
Mailing Address - Fax:601-206-6052
Practice Address - Street 1:130 PARKWAY PLZ
Practice Address - Street 2:
Practice Address - City:KOSCIUSKO
Practice Address - State:MS
Practice Address - Zip Code:39090-3217
Practice Address - Country:US
Practice Address - Phone:662-289-3588
Practice Address - Fax:662-289-2486
Is Sole Proprietor?:No
Enumeration Date:2006-04-11
Last Update Date:2013-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSOT1622225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00273305Medicaid
MS670000051Medicare ID - Type Unspecified
MS00273305Medicaid