Healthcare Provider Details

I. General information

NPI: 1700202272
Provider Name (Legal Business Name): KRISTINA FULLER LPCC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: KRISTINA WATT LPCC

II. Dates (important events)

Enumeration Date: 03/08/2014
Last Update Date: 07/15/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1048 ASHLEY ST
BOWLING GREEN KY
42103-2449
US

IV. Provider business mailing address

431 CLAYPOOL BOYCE RD
ALVATON KY
42122-8732
US

V. Phone/Fax

Practice location:
  • Phone: 270-904-6567
  • Fax: 270-904-6570
Mailing address:
  • Phone: 270-791-8189
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberKY0572
License Number StateKY
# 2
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number104177
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: