Provider Demographics
NPI:1952824443
Name:FULLER, KELCIE DENEA
Entity Type:Individual
Prefix:MRS
First Name:KELCIE
Middle Name:DENEA
Last Name:FULLER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2200 BROWN ST APT 201
Mailing Address - Street 2:
Mailing Address - City:WAXAHACHIE
Mailing Address - State:TX
Mailing Address - Zip Code:75165-5106
Mailing Address - Country:US
Mailing Address - Phone:972-921-4662
Mailing Address - Fax:
Practice Address - Street 1:8915 HARRY HINES BLVD
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75235-1717
Practice Address - Country:US
Practice Address - Phone:972-921-4662
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-07-17
Last Update Date:2017-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical