Provider Demographics
NPI:1891823456
Name:FULLER, ANTHONY BLAIR (LPC, MHSP)
Entity Type:Individual
Prefix:
First Name:ANTHONY
Middle Name:BLAIR
Last Name:FULLER
Suffix:
Gender:M
Credentials:LPC, MHSP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7023 ROCKINGHAM DR
Mailing Address - Street 2:
Mailing Address - City:KNOXVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37909-2525
Mailing Address - Country:US
Mailing Address - Phone:865-207-5841
Mailing Address - Fax:
Practice Address - Street 1:3457 KINGSTON PIKE
Practice Address - Street 2:
Practice Address - City:KNOXVILLE
Practice Address - State:TN
Practice Address - Zip Code:37919-4633
Practice Address - Country:US
Practice Address - Phone:865-207-5841
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-02
Last Update Date:2019-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN1700101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN1506511Medicaid