Provider Demographics
NPI:1912307380
Name:FOREMAN, FULLARD DEE JR (BA)
Entity Type:Individual
Prefix:MR
First Name:FULLARD
Middle Name:DEE
Last Name:FOREMAN
Suffix:JR
Gender:M
Credentials:BA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13952 N 147TH EAST AVE
Mailing Address - Street 2:
Mailing Address - City:COLLINSVILLE
Mailing Address - State:OK
Mailing Address - Zip Code:74021-5690
Mailing Address - Country:US
Mailing Address - Phone:918-344-2536
Mailing Address - Fax:
Practice Address - Street 1:13952 N 147TH EAST AVE
Practice Address - Street 2:
Practice Address - City:COLLINSVILLE
Practice Address - State:OK
Practice Address - Zip Code:74021-5690
Practice Address - Country:US
Practice Address - Phone:918-344-2536
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-09-03
Last Update Date:2014-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKF082462546101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor