Provider Demographics
NPI:1700209327
Name:FULLER, LARRY DEWITT JR (MA)
Entity Type:Individual
Prefix:
First Name:LARRY
Middle Name:DEWITT
Last Name:FULLER
Suffix:JR
Gender:M
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6439 BRIARWOOD CT
Mailing Address - Street 2:
Mailing Address - City:RIVERDALE
Mailing Address - State:GA
Mailing Address - Zip Code:30296-2904
Mailing Address - Country:US
Mailing Address - Phone:404-433-0307
Mailing Address - Fax:
Practice Address - Street 1:307 OLD STONE RD
Practice Address - Street 2:
Practice Address - City:VILLA RICA
Practice Address - State:GA
Practice Address - Zip Code:30180-1214
Practice Address - Country:US
Practice Address - Phone:770-459-8799
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-02-03
Last Update Date:2014-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALPC007525101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional