Provider Demographics
NPI:1578942140
Name:FULKERSON, KELLEY (LCSW)
Entity Type:Individual
Prefix:
First Name:KELLEY
Middle Name:
Last Name:FULKERSON
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2817 VEACH RD
Mailing Address - Street 2:
Mailing Address - City:OWENSBORO
Mailing Address - State:KY
Mailing Address - Zip Code:42303-6252
Mailing Address - Country:US
Mailing Address - Phone:270-832-4945
Mailing Address - Fax:270-495-4305
Practice Address - Street 1:2817 VEACH RD
Practice Address - Street 2:
Practice Address - City:OWENSBORO
Practice Address - State:KY
Practice Address - Zip Code:42303-6252
Practice Address - Country:US
Practice Address - Phone:270-240-5312
Practice Address - Fax:270-495-4305
Is Sole Proprietor?:Yes
Enumeration Date:2015-05-28
Last Update Date:2024-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY2539231041C0700X, 1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical