Provider Demographics
NPI:1013548213
Name:FULLER, REBECCA SUE (MA, LPC)
Entity Type:Individual
Prefix:
First Name:REBECCA
Middle Name:SUE
Last Name:FULLER
Suffix:
Gender:F
Credentials:MA, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1945 HARVEY RD
Mailing Address - Street 2:
Mailing Address - City:COTTAGE GROVE
Mailing Address - State:OR
Mailing Address - Zip Code:97424-1286
Mailing Address - Country:US
Mailing Address - Phone:503-803-4867
Mailing Address - Fax:
Practice Address - Street 1:132 E BROADWAY STE 301
Practice Address - Street 2:
Practice Address - City:EUGENE
Practice Address - State:OR
Practice Address - Zip Code:97401-3154
Practice Address - Country:US
Practice Address - Phone:541-579-8644
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-01-28
Last Update Date:2020-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORC3586101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor