Provider Demographics
NPI:1295087112
Name:FULLMER, BURTON (LPC)
Entity type:Individual
Prefix:
First Name:BURTON
Middle Name:
Last Name:FULLMER
Suffix:
Gender:M
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5689 S REDWOOD RD
Mailing Address - Street 2:SUITE 30
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84123-5447
Mailing Address - Country:US
Mailing Address - Phone:801-268-1715
Mailing Address - Fax:801-268-1783
Practice Address - Street 1:5689 S REDWOOD RD
Practice Address - Street 2:SUITE 30
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84123-5447
Practice Address - Country:US
Practice Address - Phone:801-268-1715
Practice Address - Fax:801-268-1783
Is Sole Proprietor?:Yes
Enumeration Date:2012-10-03
Last Update Date:2012-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT3785956004101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT3785956004OtherPROFESSIONAL LICENSE