Healthcare Provider Details

I. General information

NPI: 1114567807
Provider Name (Legal Business Name): TIMOTHY FULLER LCSW
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/09/2020
Last Update Date: 12/16/2025
Certification Date: 12/16/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

844 STEVENS AVE
PORTLAND ME
04103-2676
US

IV. Provider business mailing address

844 STEVENS AVE
PORTLAND ME
04103-2676
US

V. Phone/Fax

Practice location:
  • Phone: 207-505-0227
  • Fax:
Mailing address:
  • Phone: 207-505-0227
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberLC21772
License Number StateME

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: