MEDICARE: OLANDO WAYNE FULLER QMHP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	106S00000X	Behavior Technician	0732006726	VA

General Provider Information

NPI Number	:	1245847607
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	OLANDO WAYNE FULLER QMHP

Provider Business Mailing Address
First Line	:	2605 EAGLE ROCK CT
Second Line	:
City	:	CHESTER
State	:	VA
Zip	:	23831-7051
Country	:	US
Telephone Number	:	804-253-7075
Fax Number	:

Provider Business Practice Location Address
First Line	:	2605 EAGLE ROCK CT
Second Line	:
City	:	CHESTER
State	:	VA
Zip	:	23831-7051
Country	:	US
Telephone Number	:	804-253-7075
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/29/2020
Last Update Date	:	09/29/2020

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