Healthcare Provider Details

I. General information

NPI: 1972418416
Provider Name (Legal Business Name): KIMBERLY FULLER LMSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/18/2026
Last Update Date: 08/18/2026
Certification Date: 08/18/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

29615 TAWAS ST
MADISON HEIGHTS MI
48071-5425
US

IV. Provider business mailing address

29615 TAWAS ST
MADISON HEIGHTS MI
48071-5425
US

V. Phone/Fax

Practice location:
  • Phone: 248-589-3428
  • Fax: 248-545-6533
Mailing address:
  • Phone: 248-589-3428
  • Fax: 248-545-6533

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041S0200X
TaxonomySchool Social Worker
License Number6801085072
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: