Healthcare Provider Details

I. General information

NPI: 1275551392
Provider Name (Legal Business Name): KATY L FULLER LCSW-R
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: KATY L FOUNTAINE

II. Dates (important events)

Enumeration Date: 07/17/2006
Last Update Date: 10/07/2026
Certification Date: 10/07/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

48 EAST ST
FORT EDWARD NY
12828-1811
US

IV. Provider business mailing address

9 CAREY RD
QUEENSBURY NY
12804-7880
US

V. Phone/Fax

Practice location:
  • Phone: 518-824-8630
  • Fax: 518-824-2302
Mailing address:
  • Phone: 518-761-0300
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: