Provider Demographics
NPI:1619045770
Name:FULLER, MIA (MS,OTR,CHT)
Entity Type:Individual
Prefix:MRS
First Name:MIA
Middle Name:
Last Name:FULLER
Suffix:
Gender:F
Credentials:MS,OTR,CHT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2285 HAMPTONS XING
Mailing Address - Street 2:
Mailing Address - City:ALPHARETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30005-7415
Mailing Address - Country:US
Mailing Address - Phone:404-308-3820
Mailing Address - Fax:678-992-0302
Practice Address - Street 1:11180 STATE BRIDGE RD
Practice Address - Street 2:SUITE 305
Practice Address - City:ALPHARETTA
Practice Address - State:GA
Practice Address - Zip Code:30022-7482
Practice Address - Country:US
Practice Address - Phone:678-992-0303
Practice Address - Fax:678-992-0302
Is Sole Proprietor?:No
Enumeration Date:2006-11-30
Last Update Date:2019-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAOT000932225XH1200X, 225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
No225XH1200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistHand
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA501099970BMedicaid