Provider Demographics
NPI:1295260560
Name:FULLER, PATSY
Entity type:Individual
Prefix:
First Name:PATSY
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:PO BOX 8897
Mailing Address - Street 2:
Mailing Address - City:ALEXANDRIA
Mailing Address - State:LA
Mailing Address - Zip Code:71306-8897
Mailing Address - Country:US
Mailing Address - Phone:318-664-1838
Mailing Address - Fax:
Practice Address - Street 1:1404 5TH ST
Practice Address - Street 2:
Practice Address - City:ALEXANDRIA
Practice Address - State:LA
Practice Address - Zip Code:71301-7933
Practice Address - Country:US
Practice Address - Phone:318-619-2992
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-04-25
Last Update Date:2019-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA6997101Y00000X, 101YM0800X, 101YP2500X, 171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171M00000XOther Service ProvidersCase Manager/Care CoordinatorGroup - Single Specialty
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional