Provider Demographics
NPI:1841300134
Name:FULKS, REBECCA L (CSW)
Entity type:Individual
Prefix:
First Name:REBECCA
Middle Name:L
Last Name:FULKS
Suffix:
Gender:F
Credentials:CSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 790
Mailing Address - Street 2:
Mailing Address - City:ASHLAND
Mailing Address - State:KY
Mailing Address - Zip Code:41105-0790
Mailing Address - Country:US
Mailing Address - Phone:606-329-8588
Mailing Address - Fax:606-329-8195
Practice Address - Street 1:RR 5 BOX 800
Practice Address - Street 2:
Practice Address - City:SANDY HOOK
Practice Address - State:KY
Practice Address - Zip Code:41171-9200
Practice Address - Country:US
Practice Address - Phone:606-738-6163
Practice Address - Fax:606-738-5030
Is Sole Proprietor?:No
Enumeration Date:2006-08-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY1934104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
11658501OtherCAQH
KY30610026Medicaid