Provider Demographics
NPI:1184045585
Name:FULLER, ELLEN (LBSW, QMRP, QMHP)
Entity Type:Individual
Prefix:
First Name:ELLEN
Middle Name:
Last Name:FULLER
Suffix:
Gender:F
Credentials:LBSW, QMRP, QMHP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:789 N CLARE AVE
Mailing Address - Street 2:
Mailing Address - City:HARRISON
Mailing Address - State:MI
Mailing Address - Zip Code:48625-9194
Mailing Address - Country:US
Mailing Address - Phone:989-539-2141
Mailing Address - Fax:989-539-2143
Practice Address - Street 1:789 N CLARE AVE
Practice Address - Street 2:
Practice Address - City:HARRISON
Practice Address - State:MI
Practice Address - Zip Code:48625-9194
Practice Address - Country:US
Practice Address - Phone:989-539-2141
Practice Address - Fax:989-539-2143
Is Sole Proprietor?:Yes
Enumeration Date:2014-01-02
Last Update Date:2014-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6802060717104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker