Provider Demographics
NPI:1558412296
Name:FULTON, PAUL RUSSELL (EDD)
Entity Type:Individual
Prefix:DR
First Name:PAUL
Middle Name:RUSSELL
Last Name:FULTON
Suffix:
Gender:M
Credentials:EDD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:35 PLEASANT ST
Mailing Address - Street 2:
Mailing Address - City:NEWTON CENTER
Mailing Address - State:MA
Mailing Address - Zip Code:02459-1812
Mailing Address - Country:US
Mailing Address - Phone:617-244-0131
Mailing Address - Fax:
Practice Address - Street 1:23 PLEASANT ST
Practice Address - Street 2:SUITE 2
Practice Address - City:NEWTON CENTER
Practice Address - State:MA
Practice Address - Zip Code:02459-1836
Practice Address - Country:US
Practice Address - Phone:617-244-0131
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA4355103TC0700X, 103TF0200X, 103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Not Answered103TF0200XBehavioral Health & Social Service ProvidersPsychologistForensic
Not Answered103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAWO4223OtherBLUE CROSS PROVIDER ID
MAWO4223OtherBLUE CROSS PROVIDER ID