Provider Demographics
NPI:1023440377
Name:FULLER, JOAN N (MA, LPC)
Entity type:Individual
Prefix:MS
First Name:JOAN
Middle Name:N
Last Name:FULLER
Suffix:
Gender:F
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 1:1497 MALLARD AVE
Mailing Address - Street 2:
Mailing Address - City:BALDWIN
Mailing Address - State:WI
Mailing Address - Zip Code:54002-5561
Mailing Address - Country:US
Mailing Address - Phone:651-329-9112
Mailing Address - Fax:
Practice Address - Street 1:901 4TH ST
Practice Address - Street 2:SUITE 160
Practice Address - City:HUDSON
Practice Address - State:WI
Practice Address - Zip Code:54016-1681
Practice Address - Country:US
Practice Address - Phone:763-210-9966
Practice Address - Fax:763-210-6886
Is Sole Proprietor?:No
Enumeration Date:2013-08-08
Last Update Date:2015-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional