Provider Demographics
NPI:1780184523
Name:FULLERTON, SUSAN (SPEECH LANGUAGE PATH)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:
Last Name:FULLERTON
Suffix:
Gender:F
Credentials:SPEECH LANGUAGE PATH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:161 HOLLY ST
Mailing Address - Street 2:
Mailing Address - City:EDEN
Mailing Address - State:NC
Mailing Address - Zip Code:27288-7678
Mailing Address - Country:US
Mailing Address - Phone:276-638-1022
Mailing Address - Fax:
Practice Address - Street 1:288 LANCER LANE
Practice Address - Street 2:
Practice Address - City:MARTINSVILLE
Practice Address - State:VA
Practice Address - Zip Code:24112
Practice Address - Country:US
Practice Address - Phone:276-638-1022
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-02-19
Last Update Date:2018-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA220203920235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist