Provider Demographics
NPI:1669352654
Name:FULCHER, AUSTIN
Entity type:Individual
Prefix:
First Name:AUSTIN
Middle Name:
Last Name:FULCHER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:891 OLD DIXIE HWY S
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:GA
Mailing Address - Zip Code:31329-4014
Mailing Address - Country:US
Mailing Address - Phone:912-856-2580
Mailing Address - Fax:
Practice Address - Street 1:335 OLD RAIL RD
Practice Address - Street 2:
Practice Address - City:BLOOMINGDALE
Practice Address - State:GA
Practice Address - Zip Code:31302-4025
Practice Address - Country:US
Practice Address - Phone:912-421-0140
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-09-03
Last Update Date:2025-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAOTA003148224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant