Provider Demographics
NPI:1831651959
Name:FULTON, MELISSA SUZANNE (LMHC)
Entity Type:Individual
Prefix:MRS
First Name:MELISSA
Middle Name:SUZANNE
Last Name:FULTON
Suffix:
Gender:F
Credentials:LMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:445 MADINA CIR
Mailing Address - Street 2:
Mailing Address - City:DAVENPORT
Mailing Address - State:FL
Mailing Address - Zip Code:33837-8865
Mailing Address - Country:US
Mailing Address - Phone:407-301-5975
Mailing Address - Fax:
Practice Address - Street 1:65 3RD ST NW STE 201
Practice Address - Street 2:
Practice Address - City:WINTER HAVEN
Practice Address - State:FL
Practice Address - Zip Code:33881-4638
Practice Address - Country:US
Practice Address - Phone:863-293-1744
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-04-06
Last Update Date:2019-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMH16797101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty