Healthcare Provider Details

I. General information

NPI: 1831273275
Provider Name (Legal Business Name): MARY ALICE FULGHUM LMFT, L.P.C.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/24/2006
Last Update Date: 05/21/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9791 OLD SAINT AUGUSTINE RD
JACKSONVILLE FL
32257-6035
US

IV. Provider business mailing address

11996 LAZARETTE CT
JACKSONVILLE FL
32258-1197
US

V. Phone/Fax

Practice location:
  • Phone: 904-762-4040
  • Fax: 904-238-5078
Mailing address:
  • Phone: 904-762-4040
  • Fax: 904-238-5078

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number929
License Number StateMS
# 2
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License NumberMT 2553
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: