Provider Demographics
NPI:1952833121
Name:FULLER, KEVIN ANTONIO (MA, LPC)
Entity Type:Individual
Prefix:MR
First Name:KEVIN
Middle Name:ANTONIO
Last Name:FULLER
Suffix:
Gender:M
Credentials:MA, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:339 MAGIC OAKS CT
Mailing Address - Street 2:
Mailing Address - City:SPRING
Mailing Address - State:TX
Mailing Address - Zip Code:77388-8921
Mailing Address - Country:US
Mailing Address - Phone:281-389-1117
Mailing Address - Fax:
Practice Address - Street 1:339 MAGIC OAKS CT
Practice Address - Street 2:
Practice Address - City:SPRING
Practice Address - State:TX
Practice Address - Zip Code:77388-8921
Practice Address - Country:US
Practice Address - Phone:281-389-1117
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-03-28
Last Update Date:2017-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX72905101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional