Provider Demographics
NPI:1629505599
Name:FULLWOOD, KRYSTIN JHEREL
Entity Type:Individual
Prefix:
First Name:KRYSTIN
Middle Name:JHEREL
Last Name:FULLWOOD
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 1:6633 ALLEY RD
Mailing Address - Street 2:
Mailing Address - City:SUMMERFIELD
Mailing Address - State:NC
Mailing Address - Zip Code:27358-9203
Mailing Address - Country:US
Mailing Address - Phone:336-280-9976
Mailing Address - Fax:
Practice Address - Street 1:6633 ALLEY RD
Practice Address - Street 2:
Practice Address - City:SUMMERFIELD
Practice Address - State:NC
Practice Address - Zip Code:27358-9203
Practice Address - Country:US
Practice Address - Phone:336-280-9976
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-05-22
Last Update Date:2023-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
106S00000X
NCA19108101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician