Provider Demographics
NPI:1023870359
Name:FULTON, BRENDA R (LMSW)
Entity type:Individual
Prefix:
First Name:BRENDA
Middle Name:R
Last Name:FULTON
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:750 S WESTON CREEK LOOP
Mailing Address - Street 2:
Mailing Address - City:NAMPA
Mailing Address - State:ID
Mailing Address - Zip Code:83686-5655
Mailing Address - Country:US
Mailing Address - Phone:208-992-6530
Mailing Address - Fax:
Practice Address - Street 1:104 9TH AVE S STE A6
Practice Address - Street 2:
Practice Address - City:NAMPA
Practice Address - State:ID
Practice Address - Zip Code:83651-3809
Practice Address - Country:US
Practice Address - Phone:208-960-0365
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-01-23
Last Update Date:2025-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLMSW-44566104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker