Provider Demographics
NPI:1164513115
Name:FULLER, KRISTIN SWAFFER (LCSW)
Entity Type:Individual
Prefix:
First Name:KRISTIN
Middle Name:SWAFFER
Last Name:FULLER
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1344 MAPLE BEND TRL
Mailing Address - Street 2:
Mailing Address - City:LAWRENCEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30043-5270
Mailing Address - Country:US
Mailing Address - Phone:678-463-3905
Mailing Address - Fax:
Practice Address - Street 1:4482 COMMERCE DR
Practice Address - Street 2:SUITE 101
Practice Address - City:BUFORD
Practice Address - State:GA
Practice Address - Zip Code:30518-7512
Practice Address - Country:US
Practice Address - Phone:678-463-3905
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GACSW0036741041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical