Provider Demographics
NPI:1457816977
Name:FULLEN-BARNES, TEEA R (LPCA, LAT, ATC)
Entity Type:Individual
Prefix:
First Name:TEEA
Middle Name:R
Last Name:FULLEN-BARNES
Suffix:
Gender:F
Credentials:LPCA, LAT, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:341 CUNNINGHAM LN
Mailing Address - Street 2:
Mailing Address - City:WINCHESTER
Mailing Address - State:KY
Mailing Address - Zip Code:40391-7450
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6500 GLENRIDGE PARK PL STE 8
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40222-3450
Practice Address - Country:US
Practice Address - Phone:502-303-2449
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-02-08
Last Update Date:2023-09-06
Deactivation Date:2020-11-14
Deactivation Code:
Reactivation Date:2023-08-31
Provider Licenses
StateLicense IDTaxonomies
2255A2300X, 390200000X
KY280487101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program