Provider Demographics
NPI:1720502305
Name:FULFORD, VANESSA J (MFT)
Entity Type:Individual
Prefix:
First Name:VANESSA
Middle Name:J
Last Name:FULFORD
Suffix:
Gender:F
Credentials:MFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10114 NE 62ND ST
Mailing Address - Street 2:
Mailing Address - City:KIRKLAND
Mailing Address - State:WA
Mailing Address - Zip Code:98033-6867
Mailing Address - Country:US
Mailing Address - Phone:425-256-0690
Mailing Address - Fax:
Practice Address - Street 1:10114 NE 62ND ST
Practice Address - Street 2:
Practice Address - City:KIRKLAND
Practice Address - State:WA
Practice Address - Zip Code:98033-6867
Practice Address - Country:US
Practice Address - Phone:425-256-0690
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-07-26
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA604-147-250101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselorGroup - Single Specialty