Provider Demographics
NPI:1760849772
Name:FULTON, LAVENDEE M (LMSW)
Entity Type:Individual
Prefix:
First Name:LAVENDEE
Middle Name:M
Last Name:FULTON
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4660 MARSH RD
Mailing Address - Street 2:
Mailing Address - City:OKEMOS
Mailing Address - State:MI
Mailing Address - Zip Code:48864-2143
Mailing Address - Country:US
Mailing Address - Phone:517-347-2126
Mailing Address - Fax:517-347-7892
Practice Address - Street 1:4660 MARSH RD
Practice Address - Street 2:
Practice Address - City:OKEMOS
Practice Address - State:MI
Practice Address - Zip Code:48864-2143
Practice Address - Country:US
Practice Address - Phone:517-347-2126
Practice Address - Fax:517-347-7892
Is Sole Proprietor?:Yes
Enumeration Date:2016-01-21
Last Update Date:2016-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6801066385104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker