Provider Demographics
NPI:1952627382
Name:FULLER, DAPHNE (LPC)
Entity Type:Individual
Prefix:MS
First Name:DAPHNE
Middle Name:
Last Name:FULLER
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:201 S MCPHERSON CHURCH RD
Mailing Address - Street 2:SUITE 231
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28303-4974
Mailing Address - Country:US
Mailing Address - Phone:910-916-6657
Mailing Address - Fax:910-860-3609
Practice Address - Street 1:201 S MCPHERSON CHURCH RD
Practice Address - Street 2:SUITE 231
Practice Address - City:FAYETTEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28303-4974
Practice Address - Country:US
Practice Address - Phone:910-916-6657
Practice Address - Fax:910-860-3609
Is Sole Proprietor?:Yes
Enumeration Date:2010-04-09
Last Update Date:2012-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6104512Medicaid