Provider Demographics
NPI:1639102411
Name:FULLERTON, PAUL (LCSW, MSW)
Entity Type:Individual
Prefix:MR
First Name:PAUL
Middle Name:
Last Name:FULLERTON
Suffix:
Gender:M
Credentials:LCSW, MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8631 DELMAR BLVD
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63124-1990
Mailing Address - Country:US
Mailing Address - Phone:314-787-5100
Mailing Address - Fax:314-754-2800
Practice Address - Street 1:2800 ELM ST
Practice Address - Street 2:
Practice Address - City:SAINT CHARLES
Practice Address - State:MO
Practice Address - Zip Code:63301-4618
Practice Address - Country:US
Practice Address - Phone:314-787-5100
Practice Address - Fax:314-754-2800
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO000484251B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251B00000XAgenciesCase Management