Provider Demographics
NPI:1831273275
Name:FULGHUM, MARY ALICE (LMFT, LPC)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:ALICE
Last Name:FULGHUM
Suffix:
Gender:F
Credentials:LMFT, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11996 LAZARETTE CT
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32258-1197
Mailing Address - Country:US
Mailing Address - Phone:904-762-4040
Mailing Address - Fax:904-238-5078
Practice Address - Street 1:9791 OLD SAINT AUGUSTINE RD
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32257-6035
Practice Address - Country:US
Practice Address - Phone:904-762-4040
Practice Address - Fax:904-238-5078
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-24
Last Update Date:2012-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMT 2553106H00000X
MS929101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional