Provider Demographics
NPI:1609415058
Name:FULTZ, MOLLIE L
Entity Type:Individual
Prefix:
First Name:MOLLIE
Middle Name:L
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 1:883 MILLBRAE CT UNIT 6
Mailing Address - Street 2:
Mailing Address - City:WEST PALM BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33401-8467
Mailing Address - Country:US
Mailing Address - Phone:317-509-6367
Mailing Address - Fax:
Practice Address - Street 1:883 MILLBRAE CT
Practice Address - Street 2:
Practice Address - City:WEST PALM BEACH
Practice Address - State:FL
Practice Address - Zip Code:33401-8467
Practice Address - Country:US
Practice Address - Phone:317-509-6367
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-01-02
Last Update Date:2024-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health