Provider Demographics
NPI:1780244590
Name:FULBRIGHT, EMMA
Entity type:Individual
Prefix:
First Name:EMMA
Middle Name:
Last Name:FULBRIGHT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:415 MEDICAL DR STE D101
Mailing Address - Street 2:
Mailing Address - City:BOUNTIFUL
Mailing Address - State:UT
Mailing Address - Zip Code:84010-8905
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:327 W GORDON AVE STE 2
Practice Address - Street 2:
Practice Address - City:LAYTON
Practice Address - State:UT
Practice Address - Zip Code:84041-2381
Practice Address - Country:US
Practice Address - Phone:801-683-1062
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-06-14
Last Update Date:2019-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician