Provider Demographics
NPI:1962636712
Name:FUSSELL, KEITH BAUGUS (LPC, LMFT)
Entity Type:Individual
Prefix:MR
First Name:KEITH
Middle Name:BAUGUS
Last Name:FUSSELL
Suffix:
Gender:M
Credentials:LPC, LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2855 SUMMER OAKS DR
Mailing Address - Street 2:
Mailing Address - City:BARTLETT
Mailing Address - State:TN
Mailing Address - Zip Code:38134-3812
Mailing Address - Country:US
Mailing Address - Phone:901-382-3888
Mailing Address - Fax:
Practice Address - Street 1:2855 SUMMER OAKS DR
Practice Address - Street 2:
Practice Address - City:BARTLETT
Practice Address - State:TN
Practice Address - Zip Code:38134-3812
Practice Address - Country:US
Practice Address - Phone:901-382-3888
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-05-07
Last Update Date:2009-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN457101YP2500X
TN600106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional