Healthcare Provider Details

I. General information

NPI: 1841300134
Provider Name (Legal Business Name): REBECCA L FULKS CSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/30/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

RR 5 BOX 800
SANDY HOOK KY
41171-9200
US

IV. Provider business mailing address

PO BOX 790
ASHLAND KY
41105-0790
US

V. Phone/Fax

Practice location:
  • Phone: 606-738-6163
  • Fax: 606-738-5030
Mailing address:
  • Phone: 606-329-8588
  • Fax: 606-329-8195

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number1934
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: