Provider Demographics
NPI:1578159893
Name:FULTZ, KATLYN
Entity Type:Individual
Prefix:
First Name:KATLYN
Middle Name:
Last Name:FULTZ
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3108 ORCHARD RD
Mailing Address - Street 2:
Mailing Address - City:ASHTABULA
Mailing Address - State:OH
Mailing Address - Zip Code:44004-4424
Mailing Address - Country:US
Mailing Address - Phone:440-650-5030
Mailing Address - Fax:
Practice Address - Street 1:3418 LAKE AVE
Practice Address - Street 2:
Practice Address - City:ASHTABULA
Practice Address - State:OH
Practice Address - Zip Code:44004-5763
Practice Address - Country:US
Practice Address - Phone:440-650-5030
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-12-21
Last Update Date:2020-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)