Provider Demographics
NPI:1215319843
Name:FULLAM, SADIE JOHANNA (EDD)
Entity type:Individual
Prefix:DR
First Name:SADIE
Middle Name:JOHANNA
Last Name:FULLAM
Suffix:
Gender:F
Credentials:EDD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12 HAWTHORNE RD
Mailing Address - Street 2:
Mailing Address - City:STURBRIDGE
Mailing Address - State:MA
Mailing Address - Zip Code:01566-1219
Mailing Address - Country:US
Mailing Address - Phone:508-344-4843
Mailing Address - Fax:
Practice Address - Street 1:454 MAIN ST
Practice Address - Street 2:
Practice Address - City:STURBRIDGE
Practice Address - State:MA
Practice Address - Zip Code:01518-1216
Practice Address - Country:US
Practice Address - Phone:508-301-2933
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-06-19
Last Update Date:2025-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA77277235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist