Provider Demographics
NPI:1093964041
Name:FULLMER, NATHAN JAMES (LPC)
Entity Type:Individual
Prefix:
First Name:NATHAN
Middle Name:JAMES
Last Name:FULLMER
Suffix:
Gender:M
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:685 1ST ST
Mailing Address - Street 2:
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83401-4003
Mailing Address - Country:US
Mailing Address - Phone:208-228-7043
Mailing Address - Fax:
Practice Address - Street 1:685 1ST ST
Practice Address - Street 2:
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83401-4003
Practice Address - Country:US
Practice Address - Phone:208-228-7043
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-09-15
Last Update Date:2023-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLPC-3902101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health