=====================================================
General NPI Number Information
=====================================================
NPI Number | 1831888908
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MICHELLE FULKS, MFT APC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/04/2023
-----------------------------------------------------
Last Update Date | 05/04/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5252 BALBOA AVE
-----------------------------------------------------
City | SAN DIEGO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92117-6906
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 858-775-8500
-----------------------------------------------------
Fax | 858-724-3670
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1901 1ST AVE STE 124
-----------------------------------------------------
City | SAN DIEGO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92101-0300
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 858-775-8500
-----------------------------------------------------
Fax | 858-724-3670
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | MICHELLE FULKS
-----------------------------------------------------
Credential | LMFT
-----------------------------------------------------
Telephone | 858-775-8500
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 106H00000X
-----------------------------------------------------
Taxonomy Name | Marriage & Family Therapist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------