Provider Demographics
NPI:1700167327
Name:FULLER, RENEE H (MA CCC-SLP)
Entity Type:Individual
Prefix:
First Name:RENEE
Middle Name:H
Last Name:FULLER
Suffix:
Gender:F
Credentials:MA CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:112 PRIMROSE CIR
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:KY
Mailing Address - Zip Code:40475-6833
Mailing Address - Country:US
Mailing Address - Phone:859-623-6383
Mailing Address - Fax:877-665-7294
Practice Address - Street 1:2150 LEXINGTON RD
Practice Address - Street 2:SUITE G
Practice Address - City:RICHMOND
Practice Address - State:KY
Practice Address - Zip Code:40475-7924
Practice Address - Country:US
Practice Address - Phone:859-333-8147
Practice Address - Fax:877-665-7294
Is Sole Proprietor?:Yes
Enumeration Date:2011-09-09
Last Update Date:2011-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYKY 2579235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist