Provider Demographics
NPI:1184902629
Name:FULLER, CELINA RAE (CCC-SLP)
Entity type:Individual
Prefix:
First Name:CELINA
Middle Name:RAE
Last Name:FULLER
Suffix:
Gender:F
Credentials:CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1974 W SHORE RD
Mailing Address - Street 2:
Mailing Address - City:SALISBURY
Mailing Address - State:VT
Mailing Address - Zip Code:05769-9740
Mailing Address - Country:US
Mailing Address - Phone:802-352-4727
Mailing Address - Fax:
Practice Address - Street 1:1974 W SHORE RD
Practice Address - Street 2:
Practice Address - City:SALISBURY
Practice Address - State:VT
Practice Address - Zip Code:05769-9740
Practice Address - Country:US
Practice Address - Phone:802-352-4727
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-08-02
Last Update Date:2011-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT8045244235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
12149036OtherASHA CERTIFICATION