Provider Demographics
NPI:1497388581
Name:FULLER, BILLY CARL JR (CCC-SLP)
Entity Type:Individual
Prefix:MR
First Name:BILLY
Middle Name:CARL
Last Name:FULLER
Suffix:JR
Gender:M
Credentials:CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1007 MEADOW OAK DR
Mailing Address - Street 2:
Mailing Address - City:GREENSBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27406-8284
Mailing Address - Country:US
Mailing Address - Phone:336-608-2715
Mailing Address - Fax:
Practice Address - Street 1:13915 MOPAC SERVICE RD
Practice Address - Street 2:#200
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78728
Practice Address - Country:US
Practice Address - Phone:336-608-2715
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-02-17
Last Update Date:2020-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2202009409235Z00000X
NC13851235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Single Specialty