Provider Demographics
NPI:1629240288
Name:FULLER, SHANTEL AZURE
Entity Type:Individual
Prefix:
First Name:SHANTEL
Middle Name:AZURE
Last Name:FULLER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:SHANTEL
Other - Middle Name:AZURE
Other - Last Name:STONE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:10625 SE 362ND AVE UNIT C8
Mailing Address - Street 2:
Mailing Address - City:BORING
Mailing Address - State:OR
Mailing Address - Zip Code:97009-9746
Mailing Address - Country:US
Mailing Address - Phone:503-313-6641
Mailing Address - Fax:
Practice Address - Street 1:400 NE 7TH ST
Practice Address - Street 2:
Practice Address - City:GRESHAM
Practice Address - State:OR
Practice Address - Zip Code:97030-5604
Practice Address - Country:US
Practice Address - Phone:503-661-5455
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-03-24
Last Update Date:2008-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)