MEDICARE: MR. PAUL FULLERTON LCSW, MSW

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	251B00000X	Case Management Agency	000484	MO

General Provider Information

NPI Number	:	1639102411
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. PAUL FULLERTON LCSW, MSW

Provider Business Mailing Address
First Line	:	8631 DELMAR BLVD
Second Line	:
City	:	SAINT LOUIS
State	:	MO
Zip	:	63124-1990
Country	:	US
Telephone Number	:	314-787-5100
Fax Number	:	314-754-2800

Provider Business Practice Location Address
First Line	:	2800 ELM ST
Second Line	:
City	:	SAINT CHARLES
State	:	MO
Zip	:	63301-4618
Country	:	US
Telephone Number	:	314-787-5100
Fax Number	:	314-754-2800

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

Provider Enumeration Date	:	07/08/2006
Last Update Date	:	07/08/2007

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