Provider Demographics
NPI:1952456550
Name:FULFORD, VONCEAL
Entity Type:Individual
Prefix:
First Name:VONCEAL
Middle Name:
Last Name:FULFORD
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14847 PARTHENIA ST
Mailing Address - Street 2:
Mailing Address - City:PANORAMA CITY
Mailing Address - State:CA
Mailing Address - Zip Code:91402-2847
Mailing Address - Country:US
Mailing Address - Phone:818-920-5628
Mailing Address - Fax:
Practice Address - Street 1:14847 PARTHENIA ST
Practice Address - Street 2:
Practice Address - City:PANORAMA CITY
Practice Address - State:CA
Practice Address - Zip Code:91402-2847
Practice Address - Country:US
Practice Address - Phone:818-920-5628
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)