MEDICARE: BILL FULTON LCSW PC

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	1041C0700X	Clinical Social Worker	88-135506-3501	UT

General Provider Information

NPI Number	:	1750535787
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BILL FULTON LCSW PC

Provider Business Mailing Address
First Line	:	2290 E 4500 S
Second Line	:	SUITE 230
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84117-4492
Country	:	US
Telephone Number	:	801-278-2298
Fax Number	:

Provider Business Practice Location Address
First Line	:	2290 E 4500 S
Second Line	:	SUITE 230
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84117-4492
Country	:	US
Telephone Number	:	801-278-2298
Fax Number	:

Authorized Official
Title or Position	:	BILL FULTON LCSW PC
Name	:	MR. WILLIAM JOHN FULTON
Credential	:	LCSW
Telephone Number	:	801-278-2298

Provider Enumeration Date	:	11/04/2008
Last Update Date	:	11/04/2008

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