Provider Demographics
NPI:1548410244
Name:FULLENKAMP, SHELLEY S (LSW, LPC)
Entity Type:Individual
Prefix:MISS
First Name:SHELLEY
Middle Name:S
Last Name:FULLENKAMP
Suffix:
Gender:F
Credentials:LSW, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4761 STATE ROUTE 29
Mailing Address - Street 2:
Mailing Address - City:CELINA
Mailing Address - State:OH
Mailing Address - Zip Code:45822-8216
Mailing Address - Country:US
Mailing Address - Phone:419-584-1000
Mailing Address - Fax:419-584-1825
Practice Address - Street 1:4761 STATE ROUTE 29
Practice Address - Street 2:
Practice Address - City:CELINA
Practice Address - State:OH
Practice Address - Zip Code:45822-8216
Practice Address - Country:US
Practice Address - Phone:419-584-1000
Practice Address - Fax:419-584-1825
Is Sole Proprietor?:No
Enumeration Date:2008-09-30
Last Update Date:2012-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHC. 0027325101YP2500X
OHS. 0027325104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No104100000XBehavioral Health & Social Service ProvidersSocial Worker