Provider Demographics
NPI:1447587381
Name:FULLER, LUCILE MARTIN (MA, CCC-SLP)
Entity Type:Individual
Prefix:
First Name:LUCILE
Middle Name:MARTIN
Last Name:FULLER
Suffix:
Gender:F
Credentials:MA, CCC-SLP
Other - Prefix:
Other - First Name:MARTI
Other - Middle Name:SHAW
Other - Last Name:FULLER
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:133 SETTLERS LN
Mailing Address - Street 2:
Mailing Address - City:KURE BEACH
Mailing Address - State:NC
Mailing Address - Zip Code:28449-3943
Mailing Address - Country:US
Mailing Address - Phone:910-368-7025
Mailing Address - Fax:
Practice Address - Street 1:133 SETTLERS LN
Practice Address - Street 2:
Practice Address - City:KURE BEACH
Practice Address - State:NC
Practice Address - Zip Code:28449-3943
Practice Address - Country:US
Practice Address - Phone:910-368-7025
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-11-13
Last Update Date:2009-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC8761235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist