Healthcare Provider Details

I. General information

NPI: 1013548213
Provider Name (Legal Business Name): REBECCA SUE FULLER MA, LPC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/28/2020
Last Update Date: 04/10/2026
Certification Date: 04/10/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

132 E BROADWAY STE 301
EUGENE OR
97401-3154
US

IV. Provider business mailing address

1945 HARVEY RD
COTTAGE GROVE OR
97424-1286
US

V. Phone/Fax

Practice location:
  • Phone: 541-579-8644
  • Fax:
Mailing address:
  • Phone: 503-803-4867
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberC3586
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: