Provider Demographics
NPI:1427017573
Name:FULLER, MICKEY JOE (MA, MS, PSYD)
Entity Type:Individual
Prefix:DR
First Name:MICKEY
Middle Name:JOE
Last Name:FULLER
Suffix:
Gender:M
Credentials:MA, MS, PSYD
Other - Prefix:DR
Other - First Name:MICK
Other - Middle Name:
Other - Last Name:FULLER
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:3310 SPANISH VALLEY DR
Mailing Address - Street 2:
Mailing Address - City:MOAB
Mailing Address - State:UT
Mailing Address - Zip Code:84532-3636
Mailing Address - Country:US
Mailing Address - Phone:801-953-3113
Mailing Address - Fax:
Practice Address - Street 1:198 E CENTER ST
Practice Address - Street 2:
Practice Address - City:MOAB
Practice Address - State:UT
Practice Address - Zip Code:84532-2430
Practice Address - Country:US
Practice Address - Phone:435-259-6131
Practice Address - Fax:435-259-5369
Is Sole Proprietor?:No
Enumeration Date:2006-03-18
Last Update Date:2009-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT5329261-6006101YA0400X
UT5329261-6010101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)