Provider Demographics
NPI:1780058859
Name:FULTON, TERRENCE WILLIAM
Entity type:Individual
Prefix:MR
First Name:TERRENCE
Middle Name:WILLIAM
Last Name:FULTON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3217 DONNA AVE
Mailing Address - Street 2:
Mailing Address - City:WARREN
Mailing Address - State:MI
Mailing Address - Zip Code:48091-3945
Mailing Address - Country:US
Mailing Address - Phone:586-219-6024
Mailing Address - Fax:
Practice Address - Street 1:3217 DONNA AVE
Practice Address - Street 2:
Practice Address - City:WARREN
Practice Address - State:MI
Practice Address - Zip Code:48091-3945
Practice Address - Country:US
Practice Address - Phone:586-219-6024
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-11-30
Last Update Date:2015-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIF435789887177Medicaid
MIF435789887177Medicaid