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408 3rd St Ste 107 Farmington MN 55024-1355 | |
| (176) 376-0213 | |
| (651) 390-6136 |
| Full Name | |
|---|---|
| Speciality | Social Worker |
| Location | 408 3rd St Ste 107, Farmington, Minnesota |
| Authorized Official Name and Position | Tessa Fultz (OWNER/THERAPIST) |
| Authorized Official Contact | 7637602134 |
| Accepts Medicare Insurance | Yes. This clinic participates in medicare program and accept medicare insurance. |
| Mailing Address | Practice Location Address |
|---|---|
408 3rd St Ste 107 Farmington MN 55024-1355 Ph: (507) 649-2507 | 408 3rd St Ste 107 Farmington MN 55024-1355 Ph: (176) 376-0213 |
| NPI Number | 1780389189 |
|---|---|
| Provider Enumeration Date | 04/04/2023 |
| Last Update Date | 01/22/2024 |
| Certification Date | 01/22/2024 |
| Medicare PECOS PAC ID | 5799210522 |
|---|---|
| Medicare Enrollment ID | O20241203000906 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1780389189 | NPI | - | NPPES |
| Provider Name | Tessa Fultz |
|---|---|
| Provider Type | Practitioner - Clinical Social Worker |
| Provider Identifiers | NPI Number: 1568968204 PECOS PAC ID: 9739591926 Enrollment ID: I20201211001103 |
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