Provider Demographics
NPI:1841867595
Name:FULLER, NATHAN (LPC014076)
Entity type:Individual
Prefix:
First Name:NATHAN
Middle Name:
Last Name:FULLER
Suffix:
Gender:M
Credentials:LPC014076
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:224 HERSHELS WAY
Mailing Address - Street 2:
Mailing Address - City:CLARKESVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30523-4169
Mailing Address - Country:US
Mailing Address - Phone:912-695-5020
Mailing Address - Fax:
Practice Address - Street 1:224 HERSHELS WAY
Practice Address - Street 2:
Practice Address - City:CLARKESVILLE
Practice Address - State:GA
Practice Address - Zip Code:30523-4169
Practice Address - Country:US
Practice Address - Phone:912-695-5020
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-06-09
Last Update Date:2024-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Single Specialty