Healthcare Provider Details

I. General information

NPI: 1306700976
Provider Name (Legal Business Name): SAMUEL J FULLER MS, LPC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/09/2025
Last Update Date: 12/09/2025
Certification Date: 12/09/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

207 W GEORGIA AVE APT 202
NAMPA ID
83686-3024
US

IV. Provider business mailing address

4332 E THOMAS MILL DR
NAMPA ID
83686-3020
US

V. Phone/Fax

Practice location:
  • Phone: 307-204-7560
  • Fax:
Mailing address:
  • Phone: 208-461-1133
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number7871077
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: