Healthcare Provider Details

I. General information

NPI: 1306758040
Provider Name (Legal Business Name): MAHOLLA FULLER MA, CCC-SLP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/18/2026
Last Update Date: 09/18/2026
Certification Date: 09/18/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

433 LUCINDA LN
WATERVLIET MI
49098-9367
US

IV. Provider business mailing address

7151 M 140 HWY
COVERT MI
49043-9400
US

V. Phone/Fax

Practice location:
  • Phone: 269-463-0860
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: