Healthcare Provider Details

I. General information

NPI: 1265359905
Provider Name (Legal Business Name): MELISSA M FULLAM LPC-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/02/2026
Last Update Date: 07/02/2026
Certification Date: 07/02/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9200 E MINERAL AVE STE 250
CENTENNIAL CO
80112-3459
US

IV. Provider business mailing address

7254 S XENIA CIR APT D
CENTENNIAL CO
80112-1941
US

V. Phone/Fax

Practice location:
  • Phone: 303-798-2196
  • Fax: 303-730-2418
Mailing address:
  • Phone: 303-798-2196
  • Fax: 303-730-2418

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberLPCC.0024895
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: