Provider Demographics
NPI:1558618413
Name:FULLER, ALINA DAWN (LISW)
Entity Type:Individual
Prefix:MRS
First Name:ALINA
Middle Name:DAWN
Last Name:FULLER
Suffix:
Gender:F
Credentials:LISW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4913 HARROUN RD STE 3
Mailing Address - Street 2:
Mailing Address - City:SYLVANIA
Mailing Address - State:OH
Mailing Address - Zip Code:43560-2102
Mailing Address - Country:US
Mailing Address - Phone:419-841-3003
Mailing Address - Fax:
Practice Address - Street 1:4913 HARROUN RD STE 3
Practice Address - Street 2:
Practice Address - City:SYLVANIA
Practice Address - State:OH
Practice Address - Zip Code:43560-2102
Practice Address - Country:US
Practice Address - Phone:419-841-3003
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-08-10
Last Update Date:2012-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHI10001931041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical