Provider Demographics
NPI:1013322999
Name:FULKERSON, MAUREEN (MED, LPC)
Entity Type:Individual
Prefix:
First Name:MAUREEN
Middle Name:
Last Name:FULKERSON
Suffix:
Gender:F
Credentials:MED, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5675 STONE RD
Mailing Address - Street 2:
Mailing Address - City:CENTREVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:20120-1667
Mailing Address - Country:US
Mailing Address - Phone:703-862-2206
Mailing Address - Fax:
Practice Address - Street 1:5675 STONE RD
Practice Address - Street 2:SUITE 300
Practice Address - City:CENTREVILLE
Practice Address - State:VA
Practice Address - Zip Code:20120-1667
Practice Address - Country:US
Practice Address - Phone:571-289-6725
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-06-30
Last Update Date:2014-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0701005684101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional