Provider Demographics
NPI:1982838124
Name:FULMER, DOUGLAS RICHARD (MDIV, LCSW)
Entity Type:Individual
Prefix:
First Name:DOUGLAS
Middle Name:RICHARD
Last Name:FULMER
Suffix:
Gender:M
Credentials:MDIV, LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14514 MALLARD DR
Mailing Address - Street 2:
Mailing Address - City:HOMER GLEN
Mailing Address - State:IL
Mailing Address - Zip Code:60491-9263
Mailing Address - Country:US
Mailing Address - Phone:708-227-5184
Mailing Address - Fax:
Practice Address - Street 1:11309 DISTINCTIVE DR
Practice Address - Street 2:SUITE #3
Practice Address - City:ORLAND PARK
Practice Address - State:IL
Practice Address - Zip Code:60467-9490
Practice Address - Country:US
Practice Address - Phone:708-227-5184
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-05-02
Last Update Date:2009-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1490133591041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical