Provider Demographics
NPI:1568450708
Name:FULLER, MERLANE C (LISW)
Entity Type:Individual
Prefix:MRS
First Name:MERLANE
Middle Name:C
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 1:60 MESSIMER DR
Mailing Address - Street 2:
Mailing Address - City:NEWARK
Mailing Address - State:OH
Mailing Address - Zip Code:43055-1842
Mailing Address - Country:US
Mailing Address - Phone:740-522-2230
Mailing Address - Fax:740-522-6230
Practice Address - Street 1:60 MESSIMER DR
Practice Address - Street 2:
Practice Address - City:NEWARK
Practice Address - State:OH
Practice Address - Zip Code:43055-1842
Practice Address - Country:US
Practice Address - Phone:740-522-2230
Practice Address - Fax:740-522-6230
Is Sole Proprietor?:No
Enumeration Date:2005-10-12
Last Update Date:2011-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHLISW I 1584104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
S44564Medicare UPIN
FUSW22471Medicare ID - Type Unspecified