Individual
DIANE FULTZ
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
F
Credential
LCDCII, SWA, QMHS
Contact information
Practice address
7232 JUSTIN WAY, MENTOR, OH 44060-4881
(440) 578-8200
Mailing address
7232 JUSTIN WAY, MENTOR, OH 44060-4881
(440) 578-8200
Taxonomy
Speciality
Code
Description
License number
State
101YA0400X
Addiction (Substance Use Disorder) Counselor
Primary
LCDCII.161560
OH
171M00000X
Case Manager/Care Coordinator
W.1300044
OH
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
0341565
—
OH
Enumeration date
11/13/2017
Last updated
10/24/2021
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