Provider Demographics
NPI:1982950929
Name:FULLER, LAURA A (MS, LPC, ATR)
Entity Type:Individual
Prefix:
First Name:LAURA
Middle Name:A
Last Name:FULLER
Suffix:
Gender:F
Credentials:MS, LPC, ATR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:114 ORCHARD LAKE RD
Mailing Address - Street 2:
Mailing Address - City:PONTIAC
Mailing Address - State:MI
Mailing Address - Zip Code:48341-2244
Mailing Address - Country:US
Mailing Address - Phone:248-858-7766
Mailing Address - Fax:
Practice Address - Street 1:114 ORCHARD LAKE RD
Practice Address - Street 2:
Practice Address - City:PONTIAC
Practice Address - State:MI
Practice Address - Zip Code:48341-2244
Practice Address - Country:US
Practice Address - Phone:248-858-7766
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-07-27
Last Update Date:2014-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6401013190101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional