Healthcare Provider Details

I. General information

NPI: 1457816977
Provider Name (Legal Business Name): TEEA R FULLEN-BARNES LPCA, LAT, ATC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/08/2019
Last Update Date: 09/06/2023
Certification Date: 09/06/2023
Deactivation Date: 11/14/2020
Reactivation Date: 08/31/2023

III. Provider practice location address

6500 GLENRIDGE PARK PL STE 8
LOUISVILLE KY
40222-3450
US

IV. Provider business mailing address

341 CUNNINGHAM LN
WINCHESTER KY
40391-7450
US

V. Phone/Fax

Practice location:
  • Phone: 502-303-2449
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number280487
License Number StateKY
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: