Provider Demographics
NPI:1831202613
Name:FULLER, CLIFTON HENRY (LCSW, LPC, LMFT)
Entity type:Individual
Prefix:MR
First Name:CLIFTON
Middle Name:HENRY
Last Name:FULLER
Suffix:
Gender:M
Credentials:LCSW, LPC, LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12951 HUEBNER RD
Mailing Address - Street 2:STE 781466
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78230-9998
Mailing Address - Country:US
Mailing Address - Phone:210-970-1511
Mailing Address - Fax:
Practice Address - Street 1:12951 HUEBNER RD
Practice Address - Street 2:STE 781466
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78230-9998
Practice Address - Country:US
Practice Address - Phone:210-970-1511
Practice Address - Fax:210-614-9911
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-16
Last Update Date:2023-08-28
Deactivation Date:2023-01-06
Deactivation Code:
Reactivation Date:2023-03-27
Provider Licenses
StateLicense IDTaxonomies
TX#09189101YP2500X
TX9189101YP2500X
TX1081106H00000X
TX2991041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX742637802OtherEMPLOYEE IDENTIFICATION #