Provider Demographics
NPI:1013126754
Name:ELIZABETH FULTON
Entity Type:Organization
Organization Name:ELIZABETH FULTON
Other - Org Name:PALLADIA, INC.
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PROGRAM MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:ELIZABETH
Authorized Official - Middle Name:
Authorized Official - Last Name:FULTON
Authorized Official - Suffix:
Authorized Official - Credentials:BS
Authorized Official - Phone:718-299-3300
Mailing Address - Street 1:1360 CLINTON AVE
Mailing Address - Street 2:APT. 2-D
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10456-2535
Mailing Address - Country:US
Mailing Address - Phone:917-405-8608
Mailing Address - Fax:718-299-5905
Practice Address - Street 1:1360 CLINTON AVE
Practice Address - Street 2:APT. 2-D
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10456-2535
Practice Address - Country:US
Practice Address - Phone:917-405-8608
Practice Address - Fax:718-299-5905
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-21
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY003121324500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility