Provider Demographics
NPI:1629372644
Name:INGRID FULTON-EDWARDS, LCSW
Entity Type:Organization
Organization Name:INGRID FULTON-EDWARDS, LCSW
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/CLINICIAN
Authorized Official - Prefix:
Authorized Official - First Name:INGRID
Authorized Official - Middle Name:
Authorized Official - Last Name:FULTON-EDWARDS
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:412-398-3578
Mailing Address - Street 1:522 FIRETHORN DR
Mailing Address - Street 2:
Mailing Address - City:MONROEVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:15146-1617
Mailing Address - Country:US
Mailing Address - Phone:412-398-3578
Mailing Address - Fax:412-373-3276
Practice Address - Street 1:733 N HIGHLAND AVE
Practice Address - Street 2:
Practice Address - City:PITTSBURGH
Practice Address - State:PA
Practice Address - Zip Code:15206-2573
Practice Address - Country:US
Practice Address - Phone:412-398-3578
Practice Address - Fax:412-373-3276
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-01-05
Last Update Date:2011-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PACW0153171041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1018523620001Medicaid