Provider Demographics
NPI:1275133068
Name:FULLER, SONYA LATRICE (MSW, LISW-S)
Entity Type:Individual
Prefix:MRS
First Name:SONYA
Middle Name:LATRICE
Last Name:FULLER
Suffix:
Gender:F
Credentials:MSW, LISW-S
Other - Prefix:MRS
Other - First Name:SONYA
Other - Middle Name:LATRICE
Other - Last Name:REMBERT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MSW, LISW-S
Mailing Address - Street 1:38616 FAIRWAY GLENN BLVD
Mailing Address - Street 2:
Mailing Address - City:WILLOUGHBY
Mailing Address - State:OH
Mailing Address - Zip Code:44094-7188
Mailing Address - Country:US
Mailing Address - Phone:216-326-4752
Mailing Address - Fax:
Practice Address - Street 1:38616 FAIRWAY GLENN BLVD
Practice Address - Street 2:
Practice Address - City:WILLOUGHBY
Practice Address - State:OH
Practice Address - Zip Code:44094-7188
Practice Address - Country:US
Practice Address - Phone:216-326-4752
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-29
Last Update Date:2020-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHI.1600316-SUPV1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical