1962749721 NPI number — MS. CYNTHIA COLLEEN FULFORD LSCSW

Table of content: MS. CYNTHIA COLLEEN FULFORD LSCSW (NPI 1962749721)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1962749721 NPI number — MS. CYNTHIA COLLEEN FULFORD LSCSW

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
FULFORD
Provider First Name:
CYNTHIA
Provider Middle Name:
COLLEEN
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
LSCSW
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1962749721
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/02/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2022 S WEBB RD STE 261
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WICHITA
Provider Business Mailing Address State Name:
KS
Provider Business Mailing Address Postal Code:
67207-5627
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
316-258-2409
Provider Business Mailing Address Fax Number:
316-634-3075

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
9415 E HARRY ST STE 305
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WICHITA
Provider Business Practice Location Address State Name:
KS
Provider Business Practice Location Address Postal Code:
67207-5077
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
316-258-2409
Provider Business Practice Location Address Fax Number:
316-285-0527
Provider Enumeration Date:
01/13/2013

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 1041C0700X , with the licence number:  3767 , registered in the state of KS ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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