=====================================================
General NPI Number Information
=====================================================
NPI Number | 1598416703
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | D. FULTON FAMILY THERAPY INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/10/2022
-----------------------------------------------------
Last Update Date | 01/15/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 137 N OAK PARK AVE STE 216
-----------------------------------------------------
City | OAK PARK
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60301-1340
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 626-460-0707
-----------------------------------------------------
Fax | 708-406-2123
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 137 N OAK PARK AVE STE 216
-----------------------------------------------------
City | OAK PARK
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60301-1340
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 626-460-0707
-----------------------------------------------------
Fax | 708-406-2123
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DANIEL FULTON
-----------------------------------------------------
Credential | LMFT
-----------------------------------------------------
Telephone | 314-363-4136
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 106H00000X
-----------------------------------------------------
Taxonomy Name | Marriage & Family Therapist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------