Provider Demographics
NPI:1205023553
Name:FULLER, LINDA LEE (MS)
Entity Type:Individual
Prefix:
First Name:LINDA
Middle Name:LEE
Last Name:FULLER
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 481
Mailing Address - Street 2:
Mailing Address - City:LA POINTE
Mailing Address - State:WI
Mailing Address - Zip Code:54850-0481
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2334 BENJAMIN BLVD.
Practice Address - Street 2:
Practice Address - City:LA POINTE
Practice Address - State:WI
Practice Address - Zip Code:54850-0481
Practice Address - Country:US
Practice Address - Phone:715-747-2233
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-10-01
Last Update Date:2008-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI27831231041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI39239700Medicaid