Provider Demographics
NPI:1104390418
Name:FULLER, VALERIE (MS, SLP)
Entity Type:Individual
Prefix:
First Name:VALERIE
Middle Name:
Last Name:FULLER
Suffix:
Gender:F
Credentials:MS, SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:506 BUFFALO SUBDIVISION
Mailing Address - Street 2:
Mailing Address - City:LIVINGSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77351-8473
Mailing Address - Country:US
Mailing Address - Phone:936-328-9435
Mailing Address - Fax:
Practice Address - Street 1:1620 HIGHWAY 59 LOOP N
Practice Address - Street 2:
Practice Address - City:LIVINGSTON
Practice Address - State:TX
Practice Address - Zip Code:77351-9988
Practice Address - Country:US
Practice Address - Phone:936-327-5415
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-01-20
Last Update Date:2019-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX114472235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist