MEDICARE: EDEN FULTZ MA, LSW

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	104100000X	Social Worker	150118459	IL

General Provider Information

NPI Number	:	1093660136
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	EDEN FULTZ MA, LSW

Provider Business Mailing Address
First Line	:	25 E WASHINGTON ST STE 1458
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60602-1856
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	25 E WASHINGTON ST STE 1458
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60602-1856
Country	:	US
Telephone Number	:	708-568-1344
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/03/2026
Last Update Date	:	03/03/2026

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