Healthcare Provider Details

I. General information

NPI: 1669061453
Provider Name (Legal Business Name): CALLIE BROOKE FULLER MSW, CSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/15/2021
Last Update Date: 08/31/2021
Certification Date: 08/31/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

901 LEHMAN AVE STE 7
BOWLING GREEN KY
42101-4903
US

IV. Provider business mailing address

10100 ELIDA RD
DELPHOS OH
45833-9058
US

V. Phone/Fax

Practice location:
  • Phone: 270-904-6307
  • Fax: 270-904-6314
Mailing address:
  • Phone: 419-695-8010
  • Fax: 419-695-0004

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number255683
License Number StateKY
# 2
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number255987
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: