Provider Demographics
NPI:1275803702
Name:FULLER, JOANN
Entity Type:Individual
Prefix:MS
First Name:JOANN
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 1:179 PEPPERRELL RD
Mailing Address - Street 2:
Mailing Address - City:KITTERY POINT
Mailing Address - State:ME
Mailing Address - Zip Code:03905-5114
Mailing Address - Country:US
Mailing Address - Phone:207-439-9160
Mailing Address - Fax:
Practice Address - Street 1:470 FOREST AVE
Practice Address - Street 2:SUITE 202
Practice Address - City:PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04101
Practice Address - Country:US
Practice Address - Phone:207-774-3570
Practice Address - Fax:207-774-3540
Is Sole Proprietor?:Yes
Enumeration Date:2011-12-30
Last Update Date:2011-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEXL3862101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health