Provider Demographics
NPI:1760941660
Name:FULLER, TIFFANY (EDD, NCC, LCPC)
Entity Type:Individual
Prefix:DR
First Name:TIFFANY
Middle Name:
Last Name:FULLER
Suffix:
Gender:F
Credentials:EDD, NCC, LCPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9470 ANNAPOLIS RD # 114
Mailing Address - Street 2:
Mailing Address - City:LANHAM
Mailing Address - State:MD
Mailing Address - Zip Code:20706-3025
Mailing Address - Country:US
Mailing Address - Phone:301-204-9677
Mailing Address - Fax:
Practice Address - Street 1:9470 ANNAPOLIS RD # 114
Practice Address - Street 2:
Practice Address - City:LANHAM
Practice Address - State:MD
Practice Address - Zip Code:20706-3025
Practice Address - Country:US
Practice Address - Phone:301-204-9677
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-03-19
Last Update Date:2019-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDLC9407101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD459007400Medicaid