Healthcare Provider Details

I. General information

NPI: 1215453121
Provider Name (Legal Business Name): MICHELLE FULLER HARRIS LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MICHELLE LEIGH FULLER LCSW

II. Dates (important events)

Enumeration Date: 08/22/2017
Last Update Date: 07/27/2020
Certification Date: 07/27/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

39094 N ANGELLE CT
GONZALES LA
70737
US

IV. Provider business mailing address

PO BOX 96
DUPLESSIS LA
70728-0096
US

V. Phone/Fax

Practice location:
  • Phone: 225-931-2653
  • Fax: 225-677-8666
Mailing address:
  • Phone: 225-931-2653
  • Fax: 225-677-8666

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number3757
License Number StateLA
# 2
Primary TaxonomyN
Taxonomy Code1041S0200X
TaxonomySchool Social Worker
License NumberAN550373
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: