Healthcare Provider Details

I. General information

NPI: 1154725315
Provider Name (Legal Business Name): MR. FRED FULTON IV
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/17/2014
Last Update Date: 06/02/2021
Certification Date: 06/02/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

501 BROADWAY ST
DELHI LA
71232-3001
US

IV. Provider business mailing address

109 LARCHE DR
WEST MONROE LA
71291-5401
US

V. Phone/Fax

Practice location:
  • Phone: 318-878-8658
  • Fax:
Mailing address:
  • Phone: 318-651-9626
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code101YP1600X
TaxonomyPastoral Counselor
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: