Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 101YA0400X | Addiction Counselor (Substance Use Disorder) | 0710102773 | VA |
Y | 1041C0700X | Clinical Social Worker | 0904007103 | VA |
NPI | 1003241209 |
---|---|
Provider Name | Ms. Shannon Noelle Fulcrod |
First Address | Fredericksburg, VA 22404-7961 |
Second Address | Fredericksburg, VA 22401-4456 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 06/09/2013 |
Last Update Date | 06/09/2013 |