Provider Demographics
NPI:1205046398
Name:FULLERTON, MONICA ANNE (LISW)
Entity type:Individual
Prefix:
First Name:MONICA
Middle Name:ANNE
Last Name:FULLERTON
Suffix:
Gender:F
Credentials:LISW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:414 KEATHLEY DR
Mailing Address - Street 2:
Mailing Address - City:LAS CRUCES
Mailing Address - State:NM
Mailing Address - Zip Code:88005-1614
Mailing Address - Country:US
Mailing Address - Phone:505-649-8023
Mailing Address - Fax:
Practice Address - Street 1:3751 DEL REY BLVD
Practice Address - Street 2:
Practice Address - City:LAS CRUCES
Practice Address - State:NM
Practice Address - Zip Code:88012-7710
Practice Address - Country:US
Practice Address - Phone:505-556-7884
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMI-064601041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical