Provider Demographics
NPI:1922567965
Name:FULLER, ALAN J (CADC II)
Entity Type:Individual
Prefix:
First Name:ALAN
Middle Name:J
Last Name:FULLER
Suffix:
Gender:M
Credentials:CADC II
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 4236
Mailing Address - Street 2:
Mailing Address - City:MARYVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37802-4236
Mailing Address - Country:US
Mailing Address - Phone:865-603-9889
Mailing Address - Fax:
Practice Address - Street 1:2007 OLD LAFAYETTE RD
Practice Address - Street 2:
Practice Address - City:FT OGLETHORPE
Practice Address - State:GA
Practice Address - Zip Code:30742-3510
Practice Address - Country:US
Practice Address - Phone:706-861-9390
Practice Address - Fax:706-866-4740
Is Sole Proprietor?:Yes
Enumeration Date:2019-03-19
Last Update Date:2019-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA1213101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)