Healthcare Provider Details

I. General information

NPI: 1790107720
Provider Name (Legal Business Name): STEPHEN KEITH FULLER LPC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/10/2014
Last Update Date: 01/10/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

319 PARK ST
PLAINWELL MI
49080-1655
US

IV. Provider business mailing address

319 PARK ST
PLAINWELL MI
49080-1655
US

V. Phone/Fax

Practice location:
  • Phone: 269-685-9401
  • Fax: 269-685-9403
Mailing address:
  • Phone: 269-685-9401
  • Fax: 269-685-9403

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number6401008583
License Number StateMI

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: