Healthcare Provider Details

I. General information

NPI: 1912702754
Provider Name (Legal Business Name): FULLER LIVING THERAPY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/17/2025
Last Update Date: 02/17/2025
Certification Date: 02/16/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3787 RIVER RD N STE C
KEIZER OR
97303-4899
US

IV. Provider business mailing address

3787 RIVER RD N STE C
KEIZER OR
97303-4899
US

V. Phone/Fax

Practice location:
  • Phone: 619-991-0565
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DANIEL FULLER
Title or Position: THERAPIST
Credential: LPC, LMFT
Phone: 971-239-2648