Provider Demographics
NPI:1659720431
Name:FULLER, FRED D (MA, LMFT)
Entity Type:Individual
Prefix:
First Name:FRED
Middle Name:D
Last Name:FULLER
Suffix:
Gender:M
Credentials:MA, LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3500 JFK PKWY STE 210306E
Mailing Address - Street 2:
Mailing Address - City:FORT COLLINS
Mailing Address - State:CO
Mailing Address - Zip Code:80525-2635
Mailing Address - Country:US
Mailing Address - Phone:970-413-3406
Mailing Address - Fax:970-372-1068
Practice Address - Street 1:3500 JFK PKWY STE 210
Practice Address - Street 2:
Practice Address - City:FORT COLLINS
Practice Address - State:CO
Practice Address - Zip Code:80525-2635
Practice Address - Country:US
Practice Address - Phone:970-413-3406
Practice Address - Fax:970-372-1068
Is Sole Proprietor?:Yes
Enumeration Date:2016-06-13
Last Update Date:2017-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO160106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO9000149996Medicaid