MEDICARE: MRS. MELISSA SUZANNE FULTON LMHC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YM0800X	Mental Health Counselor	MH16797	FL

General Provider Information

NPI Number	:	1831651959
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. MELISSA SUZANNE FULTON LMHC

Provider Business Mailing Address
First Line	:	445 MADINA CIR
Second Line	:
City	:	DAVENPORT
State	:	FL
Zip	:	33837-8865
Country	:	US
Telephone Number	:	407-301-5975
Fax Number	:

Provider Business Practice Location Address
First Line	:	65 3RD ST NW STE 201
Second Line	:
City	:	WINTER HAVEN
State	:	FL
Zip	:	33881-4638
Country	:	US
Telephone Number	:	863-293-1744
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/06/2019
Last Update Date	:	04/06/2019

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