Provider Demographics
NPI:1033524236
Name:FULKERSON, MICHAEL HUGH (MAE, LPCC)
Entity type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:HUGH
Last Name:FULKERSON
Suffix:
Gender:M
Credentials:MAE, LPCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3731 FREDERICA ST
Mailing Address - Street 2:
Mailing Address - City:OWENSBORO
Mailing Address - State:KY
Mailing Address - Zip Code:42301-6975
Mailing Address - Country:US
Mailing Address - Phone:270-689-6681
Mailing Address - Fax:270-689-6677
Practice Address - Street 1:1100 WALNUT ST
Practice Address - Street 2:
Practice Address - City:OWENSBORO
Practice Address - State:KY
Practice Address - Zip Code:42301-2956
Practice Address - Country:US
Practice Address - Phone:270-689-6681
Practice Address - Fax:270-689-6677
Is Sole Proprietor?:Yes
Enumeration Date:2014-06-25
Last Update Date:2016-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYKY - 0223101YP2500X
KY104746101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100337270Medicaid