Provider Demographics
NPI:1578206207
Name:FULKERSON, AMANDA (LMSW)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:
Last Name:FULKERSON
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1201 E 9TH ST
Mailing Address - Street 2:
Mailing Address - City:BONHAM
Mailing Address - State:TX
Mailing Address - Zip Code:75418-4059
Mailing Address - Country:US
Mailing Address - Phone:903-583-2111
Mailing Address - Fax:
Practice Address - Street 1:1201 E 9TH ST
Practice Address - Street 2:
Practice Address - City:BONHAM
Practice Address - State:TX
Practice Address - Zip Code:75418-4059
Practice Address - Country:US
Practice Address - Phone:903-583-2111
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-04-20
Last Update Date:2022-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX34423104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker