Provider Demographics
NPI:1700843653
Name:FULTON, CYNTHIA MOON (LCSW)
Entity Type:Individual
Prefix:MRS
First Name:CYNTHIA
Middle Name:MOON
Last Name:FULTON
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:CINDI
Other - Middle Name:MOON
Other - Last Name:FULTON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:LCSW
Mailing Address - Street 1:130 KINGS DAUGHTERS DR
Mailing Address - Street 2:
Mailing Address - City:FRANKFORT
Mailing Address - State:KY
Mailing Address - Zip Code:40601-4248
Mailing Address - Country:US
Mailing Address - Phone:502-226-3300
Mailing Address - Fax:502-223-7491
Practice Address - Street 1:130 KINGS DAUGHTERS DR
Practice Address - Street 2:
Practice Address - City:FRANKFORT
Practice Address - State:KY
Practice Address - Zip Code:40601-4248
Practice Address - Country:US
Practice Address - Phone:502-226-3300
Practice Address - Fax:502-223-7491
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-26
Last Update Date:2021-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY12401041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY2081005OtherCIGNA
KY00483445OtherANTHEM
KY7100336590Medicaid