Provider Demographics
NPI:1851836993
Name:FULKS, MICHELLE K (LMFT)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:K
Last Name:FULKS
Suffix:
Gender:F
Credentials:LMFT
Other - Prefix:
Other - First Name:MICHELLE
Other - Middle Name:K
Other - Last Name:GRANIERI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LMFT
Mailing Address - Street 1:1202 MORENA BLVD
Mailing Address - Street 2:SUITE 300
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92110-3841
Mailing Address - Country:US
Mailing Address - Phone:619-276-8112
Mailing Address - Fax:
Practice Address - Street 1:1202 MORENA BLVD
Practice Address - Street 2:SUITE 300
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92110-3841
Practice Address - Country:US
Practice Address - Phone:619-276-8112
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-12-28
Last Update Date:2016-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA34979106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist