Provider Demographics
NPI:1346846151
Name:FULLER, TERESA ANTOINETTE (LCSW, LCDC)
Entity Type:Individual
Prefix:
First Name:TERESA
Middle Name:ANTOINETTE
Last Name:FULLER
Suffix:
Gender:F
Credentials:LCSW, LCDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1918 WOODVALE DR UNIT B
Mailing Address - Street 2:
Mailing Address - City:MISSOURI CITY
Mailing Address - State:TX
Mailing Address - Zip Code:77489-1421
Mailing Address - Country:US
Mailing Address - Phone:281-901-9412
Mailing Address - Fax:
Practice Address - Street 1:9898 BISSONNET ST STE 470
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77036-8280
Practice Address - Country:US
Practice Address - Phone:281-888-6137
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-12-07
Last Update Date:2021-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX14286101YA0400X
TX618101041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)