Provider Demographics
NPI:1902467350
Name:FULLWOOD, GLYNIS WIKSTROM (LCSW)
Entity Type:Individual
Prefix:
First Name:GLYNIS
Middle Name:WIKSTROM
Last Name:FULLWOOD
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:104 S ESTES DR STE 301G
Mailing Address - Street 2:
Mailing Address - City:CHAPEL HILL
Mailing Address - State:NC
Mailing Address - Zip Code:27514-2848
Mailing Address - Country:US
Mailing Address - Phone:919-931-5639
Mailing Address - Fax:
Practice Address - Street 1:104 S ESTES DR STE 301G
Practice Address - Street 2:
Practice Address - City:CHAPEL HILL
Practice Address - State:NC
Practice Address - Zip Code:27514-2848
Practice Address - Country:US
Practice Address - Phone:919-931-5639
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-06-26
Last Update Date:2019-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCC0044581041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical