Provider Demographics
NPI:1568968204
Name:FULTZ, TESSA (LICSW)
Entity Type:Individual
Prefix:
First Name:TESSA
Middle Name:
Last Name:FULTZ
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18175 FACADE AVE
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON
Mailing Address - State:MN
Mailing Address - Zip Code:55024-9498
Mailing Address - Country:US
Mailing Address - Phone:651-252-4025
Mailing Address - Fax:
Practice Address - Street 1:18598 ELK RIVER TRAIL
Practice Address - Street 2:
Practice Address - City:FARMINGTON
Practice Address - State:MN
Practice Address - Zip Code:55024
Practice Address - Country:US
Practice Address - Phone:651-333-0653
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-04-02
Last Update Date:2023-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN26216104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker