Provider Demographics
NPI:1609142488
Name:FULP, WILLIAM BROOKS JR (LMBT, MMP)
Entity type:Individual
Prefix:MR
First Name:WILLIAM
Middle Name:BROOKS
Last Name:FULP
Suffix:JR
Gender:M
Credentials:LMBT, MMP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3063 WALKERTOWN VIEW DR
Mailing Address - Street 2:P.O. BOX 1311
Mailing Address - City:WALKERTOWN
Mailing Address - State:NC
Mailing Address - Zip Code:27051-9815
Mailing Address - Country:US
Mailing Address - Phone:336-595-1222
Mailing Address - Fax:
Practice Address - Street 1:3063 WALKERTOWN VIEW DR
Practice Address - Street 2:
Practice Address - City:WALKERTOWN
Practice Address - State:NC
Practice Address - Zip Code:27051-9815
Practice Address - Country:US
Practice Address - Phone:336-595-1222
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-03-27
Last Update Date:2012-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC10155225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist