Provider Demographics
NPI:1558133249
Name:FULLER, ALLIE
Entity Type:Individual
Prefix:
First Name:ALLIE
Middle Name:
Last Name:FULLER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3611 31ST AVE APT 1H
Mailing Address - Street 2:
Mailing Address - City:ASTORIA
Mailing Address - State:NY
Mailing Address - Zip Code:11106-1081
Mailing Address - Country:US
Mailing Address - Phone:719-271-3569
Mailing Address - Fax:
Practice Address - Street 1:135 OCEAN PKWY APT 1P
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11218-2579
Practice Address - Country:US
Practice Address - Phone:347-378-7098
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-10-25
Last Update Date:2023-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health