Provider Demographics
NPI:1336411289
Name:FULLER, ANN ELIZABETH (LPC)
Entity Type:Individual
Prefix:
First Name:ANN
Middle Name:ELIZABETH
Last Name:FULLER
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:ANN
Other - Middle Name:ELIZABETH
Other - Last Name:FULLER
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LPC
Mailing Address - Street 1:15370 LEVAN RD
Mailing Address - Street 2:SUITE 2
Mailing Address - City:LIVONIA
Mailing Address - State:MI
Mailing Address - Zip Code:48154-1903
Mailing Address - Country:US
Mailing Address - Phone:248-798-8121
Mailing Address - Fax:
Practice Address - Street 1:15370 LEVAN RD STE 2
Practice Address - Street 2:
Practice Address - City:LIVONIA
Practice Address - State:MI
Practice Address - Zip Code:48154-1903
Practice Address - Country:US
Practice Address - Phone:248-798-8121
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-02-07
Last Update Date:2018-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6401010696101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional