Provider Demographics
NPI:1518037613
Name:FULLER, EARLY R (CADCIII)
Entity Type:Individual
Prefix:MR
First Name:EARLY
Middle Name:R
Last Name:FULLER
Suffix:
Gender:M
Credentials:CADCIII
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2150 MEMORIAL DR STE 213
Mailing Address - Street 2:
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54303-6335
Mailing Address - Country:US
Mailing Address - Phone:920-498-3383
Mailing Address - Fax:920-498-3705
Practice Address - Street 1:2150 MEMORIAL DR STE 213
Practice Address - Street 2:
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54303-6335
Practice Address - Country:US
Practice Address - Phone:920-498-3383
Practice Address - Fax:920-498-3705
Is Sole Proprietor?:No
Enumeration Date:2006-11-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2418101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)