Healthcare Provider Details

I. General information

NPI: 1316211691
Provider Name (Legal Business Name): CYNTHIA FULREADER LPC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/03/2012
Last Update Date: 03/03/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1919 5TH ST
SANTA FE NM
87505-5402
US

IV. Provider business mailing address

2844 VEREDA DE PUEBLO
SANTA FE NM
87507-5386
US

V. Phone/Fax

Practice location:
  • Phone: 505-795-8831
  • Fax:
Mailing address:
  • Phone: 505-473-4420
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number1808
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: