Provider Demographics
NPI:1740262120
Name:FULLER, SUSAN KAY (LCSW)
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:KAY
Last Name:FULLER
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:MS
Other - First Name:SUSAN
Other - Middle Name:HENDERSON
Other - Last Name:FULLER
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LCSW
Mailing Address - Street 1:2100 W SAN MARCELO BLVD
Mailing Address - Street 2:
Mailing Address - City:BROWNSVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:78526-1782
Mailing Address - Country:US
Mailing Address - Phone:956-371-1392
Mailing Address - Fax:
Practice Address - Street 1:2100 W SAN MARCELO BLVD
Practice Address - Street 2:
Practice Address - City:BROWNSVILLE
Practice Address - State:TX
Practice Address - Zip Code:78526-1785
Practice Address - Country:US
Practice Address - Phone:956-371-1392
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-11-18
Last Update Date:2009-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX215741041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical