Healthcare Provider Details

I. General information

NPI: 1336935733
Provider Name (Legal Business Name): JOSEPH FULLER
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/15/2025
Last Update Date: 04/15/2025
Certification Date: 04/15/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

22639 EUCLID AVE
EUCLID OH
44117-1622
US

IV. Provider business mailing address

25511 LAKE SHORE BLVD APT E18
EUCLID OH
44132-1171
US

V. Phone/Fax

Practice location:
  • Phone: 216-404-1900
  • Fax:
Mailing address:
  • Phone: 216-860-3958
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number191371
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: