Provider Demographics
NPI:1700202272
Name:FULLER, KRISTINA (LPCC)
Entity Type:Individual
Prefix:MS
First Name:KRISTINA
Middle Name:
Last Name:FULLER
Suffix:
Gender:F
Credentials:LPCC
Other - Prefix:
Other - First Name:KRISTINA
Other - Middle Name:
Other - Last Name:WATT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LPCC
Mailing Address - Street 1:431 CLAYPOOL BOYCE RD
Mailing Address - Street 2:
Mailing Address - City:ALVATON
Mailing Address - State:KY
Mailing Address - Zip Code:42122-8732
Mailing Address - Country:US
Mailing Address - Phone:270-791-8189
Mailing Address - Fax:
Practice Address - Street 1:1048 ASHLEY ST
Practice Address - Street 2:
Practice Address - City:BOWLING GREEN
Practice Address - State:KY
Practice Address - Zip Code:42103-2449
Practice Address - Country:US
Practice Address - Phone:270-904-6567
Practice Address - Fax:270-904-6570
Is Sole Proprietor?:Yes
Enumeration Date:2014-03-08
Last Update Date:2019-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYKY0572101YM0800X
KY104177101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100287000Medicaid