Provider Demographics
NPI:1770305203
Name:FULTZ, CRYSTAL LEE
Entity type:Individual
Prefix:
First Name:CRYSTAL
Middle Name:LEE
Last Name:FULTZ
Suffix:
Gender:X
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1201 AGNES ST
Mailing Address - Street 2:
Mailing Address - City:CORPUS CHRISTI
Mailing Address - State:TX
Mailing Address - Zip Code:78401-3226
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:546 DIXON DR
Practice Address - Street 2:
Practice Address - City:CORPUS CHRISTI
Practice Address - State:TX
Practice Address - Zip Code:78408-2916
Practice Address - Country:US
Practice Address - Phone:361-945-3846
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-10-28
Last Update Date:2025-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101200000X, 101200000X
TX1780079319176P00000X
TX261QP0905X207PE0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101200000XBehavioral Health & Social Service ProvidersDrama Therapist
No176P00000XOther Service ProvidersFuneral DirectorGroup - Multi-Specialty
No207PE0004XAllopathic & Osteopathic PhysiciansEmergency MedicineEmergency Medical Services
Provider Identifiers
StateIdentifier IDID TypeIssuer
103TE1000XOtherBEHAVIORAL/SOCIAL PSYCHOLOGY
1780079319Other101Y00000X