MEDICARE: ANGEL M FULLER SUDP-T

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	101YA0400X	Addiction (Substance Use Disorder) Counselor	61040159	WA

General Provider Information

NPI Number	:	1659099042
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ANGEL M FULLER SUDP-T

Provider Business Mailing Address
First Line	:	6400 SOUTHCENTER BLVD
Second Line	:
City	:	TUKWILA
State	:	WA
Zip	:	98188-2547
Country	:	US
Telephone Number	:	206-901-2000
Fax Number	:	206-901-2010

Provider Business Practice Location Address
First Line	:	11000 LAKE CITY WAY NE
Second Line	:
City	:	SEATTLE
State	:	WA
Zip	:	98125-6748
Country	:	US
Telephone Number	:	206-901-2000
Fax Number	:	206-901-2010

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

Provider Enumeration Date	:	08/22/2022
Last Update Date	:	04/06/2026

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