Provider Demographics
NPI:1720680945
Name:FULLAM, JOHN PATRICK (LPC)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:PATRICK
Last Name:FULLAM
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 1:811 MAIN CT
Mailing Address - Street 2:
Mailing Address - City:CARBONDALE
Mailing Address - State:CO
Mailing Address - Zip Code:81623-1851
Mailing Address - Country:US
Mailing Address - Phone:973-714-3036
Mailing Address - Fax:
Practice Address - Street 1:725 MAIN ST
Practice Address - Street 2:
Practice Address - City:CARBONDALE
Practice Address - State:CO
Practice Address - Zip Code:81623-1936
Practice Address - Country:US
Practice Address - Phone:973-714-3036
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-12
Last Update Date:2020-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COLPC.0016660101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
COLPC.0016660OtherSTATE LICENSE