Provider Demographics
NPI:1558918839
Name:FULTON, DANIEL P (MA)
Entity Type:Individual
Prefix:
First Name:DANIEL
Middle Name:P
Last Name:FULTON
Suffix:
Gender:M
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:137 N OAK PARK AVE STE 216
Mailing Address - Street 2:
Mailing Address - City:OAK PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60301-1340
Mailing Address - Country:US
Mailing Address - Phone:626-460-0707
Mailing Address - Fax:708-406-2123
Practice Address - Street 1:137 N OAK PARK AVE STE 216
Practice Address - Street 2:
Practice Address - City:OAK PARK
Practice Address - State:IL
Practice Address - Zip Code:60301-1340
Practice Address - Country:US
Practice Address - Phone:626-460-0707
Practice Address - Fax:708-406-2123
Is Sole Proprietor?:No
Enumeration Date:2019-08-21
Last Update Date:2024-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL166.001589106H00000X
CA124641106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist