Provider Demographics
NPI:1649747205
Name:FULFOR, LISA KIM (LCSW)
Entity Type:Individual
Prefix:MS
First Name:LISA
Middle Name:KIM
Last Name:FULFOR
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 1:13254 LIME RIDGE DR
Mailing Address - Street 2:
Mailing Address - City:FRISCO
Mailing Address - State:TX
Mailing Address - Zip Code:75033-0938
Mailing Address - Country:US
Mailing Address - Phone:214-316-0924
Mailing Address - Fax:
Practice Address - Street 1:1333 W MCDERMOTT DR
Practice Address - Street 2:
Practice Address - City:ALLEN
Practice Address - State:TX
Practice Address - Zip Code:75013-3090
Practice Address - Country:US
Practice Address - Phone:469-998-1989
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-10-31
Last Update Date:2018-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX600551041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical