Healthcare Provider Details

I. General information

NPI: 1447021621
Provider Name (Legal Business Name): THOMAS FULLER CDCA, PRS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/16/2024
Last Update Date: 01/16/2024
Certification Date: 01/16/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

408 COSHOCTON AVE
MOUNT VERNON OH
43050-2634
US

IV. Provider business mailing address

408 COSHOCTON AVE
MOUNT VERNON OH
43050-2634
US

V. Phone/Fax

Practice location:
  • Phone: 740-326-9255
  • Fax:
Mailing address:
  • Phone: 740-326-9255
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberCDCA.182930
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code175T00000X
TaxonomyPeer Specialist
License NumberAPS.002446
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: