Healthcare Provider Details

I. General information

NPI: 1386294478
Provider Name (Legal Business Name): SAVANNAH FULFORD LMHC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/19/2019
Last Update Date: 10/28/2020
Certification Date: 10/28/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

900 SE OCEAN BLVD STE D232
STUART FL
34994-3501
US

IV. Provider business mailing address

3094 NE HIGHLAND AVE
JENSEN BEACH FL
34957-7240
US

V. Phone/Fax

Practice location:
  • Phone: 772-678-0271
  • Fax:
Mailing address:
  • Phone: 863-221-2370
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberMH16494
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: