Provider Demographics
NPI:1881754836
Name:FULCO, MICHAEL NICHOLAS (PHD)
Entity type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:NICHOLAS
Last Name:FULCO
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1155 NEW BRITAIN AVE
Mailing Address - Street 2:
Mailing Address - City:WEST HARTFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06110-2486
Mailing Address - Country:US
Mailing Address - Phone:860-523-0855
Mailing Address - Fax:860-586-8782
Practice Address - Street 1:1155 NEW BRITAIN AVE
Practice Address - Street 2:
Practice Address - City:WEST HARTFORD
Practice Address - State:CT
Practice Address - Zip Code:06110-2486
Practice Address - Country:US
Practice Address - Phone:860-523-0855
Practice Address - Fax:860-586-8782
Is Sole Proprietor?:No
Enumeration Date:2006-12-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT00992103G00000X, 103TC0700X
NY06958103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
Not Answered103T00000XBehavioral Health & Social Service ProvidersPsychologist
Not Answered103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical