Provider Demographics
NPI:1740401355
Name:FULLER, LESA MONETTE (MS,CCC-SLP)
Entity Type:Individual
Prefix:
First Name:LESA
Middle Name:MONETTE
Last Name:FULLER
Suffix:
Gender:F
Credentials:MS,CCC-SLP
Other - Prefix:
Other - First Name:LESA
Other - Middle Name:
Other - Last Name:PERRY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MS,CCC-SLP
Mailing Address - Street 1:4930 SIROS ISLE COURT
Mailing Address - Street 2:
Mailing Address - City:SPRING
Mailing Address - State:TX
Mailing Address - Zip Code:77388
Mailing Address - Country:US
Mailing Address - Phone:281-288-7406
Mailing Address - Fax:
Practice Address - Street 1:4930 SIROS ISLE COURT
Practice Address - Street 2:
Practice Address - City:SPRING
Practice Address - State:TX
Practice Address - Zip Code:77388
Practice Address - Country:US
Practice Address - Phone:281-288-7406
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX101813235Z00000X
TN0000003483235Z00000X
FLSA-3964235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist