Healthcare Provider Details

I. General information

NPI: 1578497145
Provider Name (Legal Business Name): VIVIAN EBI TANYI FULTANG
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/10/2026
Last Update Date: 06/10/2026
Certification Date: 06/10/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6004 SPRINGHILL DR APT 204
GREENBELT MD
20770-3159
US

IV. Provider business mailing address

6004 SPRINGHILL DR APT 204
GREENBELT MD
20770-3159
US

V. Phone/Fax

Practice location:
  • Phone: 940-230-9835
  • Fax:
Mailing address:
  • Phone: 940-230-9835
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number StateMD
# 2
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: