Healthcare Provider Details

I. General information

NPI: 1760393672
Provider Name (Legal Business Name): BRANDON FULTON
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/17/2026
Last Update Date: 09/17/2026
Certification Date: 09/17/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

458 GRAND AVE
NEW HAVEN CT
06513-3856
US

IV. Provider business mailing address

236 NEW HAVEN AVE
DERBY CT
06418-2114
US

V. Phone/Fax

Practice location:
  • Phone: 475-269-9210
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number3963
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: