Healthcare Provider Details

I. General information

NPI: 1477751345
Provider Name (Legal Business Name): SANDI K FULTZ LPC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/03/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1608 S ELWOOD AVE
TULSA OK
74119-4208
US

IV. Provider business mailing address

10255 E 540 RD
CLAREMORE OK
74019-0297
US

V. Phone/Fax

Practice location:
  • Phone: 918-587-3888
  • Fax: 918-587-3891
Mailing address:
  • Phone: 918-587-3888
  • Fax: 918-587-3891

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number3823
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: