Provider Demographics
NPI:1790107720
Name:FULLER, STEPHEN KEITH (LPC)
Entity Type:Individual
Prefix:
First Name:STEPHEN
Middle Name:KEITH
Last Name:FULLER
Suffix:
Gender:M
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:319 PARK ST
Mailing Address - Street 2:
Mailing Address - City:PLAINWELL
Mailing Address - State:MI
Mailing Address - Zip Code:49080-1655
Mailing Address - Country:US
Mailing Address - Phone:269-685-9401
Mailing Address - Fax:269-685-9403
Practice Address - Street 1:319 PARK ST
Practice Address - Street 2:
Practice Address - City:PLAINWELL
Practice Address - State:MI
Practice Address - Zip Code:49080-1655
Practice Address - Country:US
Practice Address - Phone:269-685-9401
Practice Address - Fax:269-685-9403
Is Sole Proprietor?:No
Enumeration Date:2014-01-10
Last Update Date:2014-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6401008583101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional