Healthcare Provider Details

I. General information

NPI: 1053245589
Provider Name (Legal Business Name): MR. DIMITRI FULLER
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/10/2026
Last Update Date: 06/10/2026
Certification Date: 06/10/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

22018 S CENTRAL POINT RD
CANBY OR
97013-8705
US

IV. Provider business mailing address

1227 JOHNSON ST
OREGON CITY OR
97045-3610
US

V. Phone/Fax

Practice location:
  • Phone: 503-221-4531
  • Fax:
Mailing address:
  • Phone: 503-597-9082
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: