Provider Demographics
NPI:1780634196
Name:FULLHART, THERESA K (MSW)
Entity Type:Individual
Prefix:MS
First Name:THERESA
Middle Name:K
Last Name:FULLHART
Suffix:
Gender:F
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:905 MONTGOMERY ST
Mailing Address - Street 2:
Mailing Address - City:DECORAH
Mailing Address - State:IA
Mailing Address - Zip Code:52101-2325
Mailing Address - Country:US
Mailing Address - Phone:563-382-3649
Mailing Address - Fax:563-382-8183
Practice Address - Street 1:905 MONTGOMERY STREET
Practice Address - Street 2:
Practice Address - City:DECORAH
Practice Address - State:IA
Practice Address - Zip Code:52101
Practice Address - Country:US
Practice Address - Phone:563-382-3649
Practice Address - Fax:563-382-8183
Is Sole Proprietor?:No
Enumeration Date:2006-05-10
Last Update Date:2010-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA058661041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA074550001Medicare PIN