Provider Demographics
NPI:1225495690
Name:FULLER, SANDRA
Entity Type:Individual
Prefix:
First Name:SANDRA
Middle Name:
Last Name:FULLER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:409 BROAD RIPPLE DR
Mailing Address - Street 2:
Mailing Address - City:HUFFMAN
Mailing Address - State:TX
Mailing Address - Zip Code:77336-2877
Mailing Address - Country:US
Mailing Address - Phone:281-620-4826
Mailing Address - Fax:
Practice Address - Street 1:19814 ATASCOCITA SHORES DR
Practice Address - Street 2:
Practice Address - City:HUMBLE
Practice Address - State:TX
Practice Address - Zip Code:77346-2343
Practice Address - Country:US
Practice Address - Phone:832-772-4292
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-01-15
Last Update Date:2016-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP1600XBehavioral Health & Social Service ProvidersCounselorPastoral