MEDICARE: LISA MAUREEN FULTON LADC

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	101YA0400X	Addiction (Substance Use Disorder) Counselor	302392	MN

General Provider Information

NPI Number	:	1861327108
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LISA MAUREEN FULTON LADC

Provider Business Mailing Address
First Line	:	412 W SUPERIOR ST
Second Line	:
City	:	DULUTH
State	:	MN
Zip	:	55802-1512
Country	:	US
Telephone Number	:	218-481-4019
Fax Number	:

Provider Business Practice Location Address
First Line	:	412 W SUPERIOR ST
Second Line	:
City	:	DULUTH
State	:	MN
Zip	:	55802-1512
Country	:	US
Telephone Number	:	218-481-4019
Fax Number	:

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

Provider Enumeration Date	:	06/17/2026
Last Update Date	:	06/17/2026

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