Healthcare Provider Details

I. General information

NPI: 1760705735
Provider Name (Legal Business Name): JOSEPH FULLEN ACDP, ICADC, LMHC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/05/2010
Last Update Date: 05/03/2025
Certification Date: 05/03/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

20 HAMILTON DR
EAST GREENWICH RI
02818-2109
US

IV. Provider business mailing address

PO BOX 553
EAST GREENWICH RI
02818-0553
US

V. Phone/Fax

Practice location:
  • Phone: 401-516-4204
  • Fax:
Mailing address:
  • Phone: 401-516-4204
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberCDP00201
License Number StateRI
# 2
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberMHC00788
License Number StateRI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: