Provider Demographics
NPI:1457503468
Name:FULLER, JOHN EDWARD (LCSW-C)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:EDWARD
Last Name:FULLER
Suffix:
Gender:M
Credentials:LCSW-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8303 COLESVILLE RD
Mailing Address - Street 2:
Mailing Address - City:SILVER SPRING
Mailing Address - State:MD
Mailing Address - Zip Code:20910-3203
Mailing Address - Country:US
Mailing Address - Phone:202-445-7522
Mailing Address - Fax:
Practice Address - Street 1:8303 COLESVILLE RD
Practice Address - Street 2:
Practice Address - City:SILVER SPRING
Practice Address - State:MD
Practice Address - Zip Code:20910-3203
Practice Address - Country:US
Practice Address - Phone:202-445-7522
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-10-21
Last Update Date:2014-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD137141041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical