Provider Demographics
NPI:1659576841
Name:FULLER, BRIAN (MS, LMSW, LMHP)
Entity Type:Individual
Prefix:MR
First Name:BRIAN
Middle Name:
Last Name:FULLER
Suffix:
Gender:M
Credentials:MS, LMSW, LMHP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:500 WILLOW AVE
Mailing Address - Street 2:SUITE 305
Mailing Address - City:COUNCIL BLUFFS
Mailing Address - State:IA
Mailing Address - Zip Code:51503-0827
Mailing Address - Country:US
Mailing Address - Phone:712-256-4420
Mailing Address - Fax:712-256-4423
Practice Address - Street 1:500 WILLOW AVE
Practice Address - Street 2:SUITE 305
Practice Address - City:COUNCIL BLUFFS
Practice Address - State:IA
Practice Address - Zip Code:51503-0827
Practice Address - Country:US
Practice Address - Phone:712-256-4420
Practice Address - Fax:712-256-4423
Is Sole Proprietor?:No
Enumeration Date:2007-06-18
Last Update Date:2008-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE1978101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA1010744Medicaid
NE100253517-00Medicaid