Provider Demographics
NPI:1871901710
Name:FULS, BRE'LYSE L (LISW-S)
Entity type:Individual
Prefix:
First Name:BRE'LYSE
Middle Name:L
Last Name:FULS
Suffix:
Gender:F
Credentials:LISW-S
Other - Prefix:
Other - First Name:BRELYSE
Other - Middle Name:L
Other - Last Name:THORNTON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LSW
Mailing Address - Street 1:615 ELSINORE PL STE 200
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45202-1459
Mailing Address - Country:US
Mailing Address - Phone:513-834-7063
Mailing Address - Fax:513-873-1567
Practice Address - Street 1:3768 E MAIN ST
Practice Address - Street 2:
Practice Address - City:WHITEHALL
Practice Address - State:OH
Practice Address - Zip Code:43213-2925
Practice Address - Country:US
Practice Address - Phone:513-834-7063
Practice Address - Fax:513-873-1567
Is Sole Proprietor?:No
Enumeration Date:2014-07-23
Last Update Date:2020-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHI.1700565-SUPV104100000X
OHI.17005651041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical