Provider Demographics
NPI:1629554621
Name:FULFORTH, HALEY (AUD)
Entity type:Individual
Prefix:DR
First Name:HALEY
Middle Name:
Last Name:FULFORTH
Suffix:
Gender:F
Credentials:AUD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20 ORTIZ DR
Mailing Address - Street 2:
Mailing Address - City:PENNSAUKEN
Mailing Address - State:NJ
Mailing Address - Zip Code:08110-1250
Mailing Address - Country:US
Mailing Address - Phone:215-514-0760
Mailing Address - Fax:
Practice Address - Street 1:1650 MARKET ST
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19103-7301
Practice Address - Country:US
Practice Address - Phone:215-514-0760
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-07-13
Last Update Date:2024-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAAT006575231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1780016360Medicaid