Provider Demographics
NPI:1932681855
Name:FULWOOD, OPAL A (MA)
Entity Type:Individual
Prefix:
First Name:OPAL
Middle Name:A
Last Name:FULWOOD
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6334 SAINT ANDREWS RD STE 204
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29212-3143
Mailing Address - Country:US
Mailing Address - Phone:803-764-0961
Mailing Address - Fax:803-764-0961
Practice Address - Street 1:6334 SAINT ANDREWS RD STE 204
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29212-3143
Practice Address - Country:US
Practice Address - Phone:803-764-0961
Practice Address - Fax:803-764-0961
Is Sole Proprietor?:No
Enumeration Date:2018-09-06
Last Update Date:2018-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC6926101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional