Provider Demographics
NPI:1952845240
Name:FULLER, CHARLES ROBERT II (LPC-S)
Entity Type:Individual
Prefix:MR
First Name:CHARLES
Middle Name:ROBERT
Last Name:FULLER
Suffix:II
Gender:M
Credentials:LPC-S
Other - Prefix:
Other - First Name:ROBBIE
Other - Middle Name:
Other - Last Name:FULLER
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:LPC-S
Mailing Address - Street 1:1716 BRIARCREST DR STE 300
Mailing Address - Street 2:
Mailing Address - City:BRYAN
Mailing Address - State:TX
Mailing Address - Zip Code:77802-2777
Mailing Address - Country:US
Mailing Address - Phone:979-431-5413
Mailing Address - Fax:
Practice Address - Street 1:3201 UNIVERSITY DR E STE 150
Practice Address - Street 2:
Practice Address - City:BRYAN
Practice Address - State:TX
Practice Address - Zip Code:77802-3487
Practice Address - Country:US
Practice Address - Phone:979-777-5545
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-12-06
Last Update Date:2023-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX72142101Y00000X, 101YM0800X, 101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health