Provider Demographics
NPI:1538641097
Name:FULLERTON, VICTORIA ALEXANDER (MSW)
Entity Type:Individual
Prefix:
First Name:VICTORIA
Middle Name:ALEXANDER
Last Name:FULLERTON
Suffix:
Gender:F
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3001 INDIANOLA AVE
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43202-1303
Mailing Address - Country:US
Mailing Address - Phone:614-706-1341
Mailing Address - Fax:
Practice Address - Street 1:3001 INDIANOLA AVE
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43202-1303
Practice Address - Country:US
Practice Address - Phone:614-706-1341
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-31
Last Update Date:2023-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHS.1700552104100000X
OHI.22037291041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH1473276Medicaid