Healthcare Provider Details

I. General information

NPI: 1952845240
Provider Name (Legal Business Name): CHARLES ROBERT FULLER II LPC-S
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: ROBBIE FULLER LPC-S

II. Dates (important events)

Enumeration Date: 12/06/2016
Last Update Date: 07/23/2026
Certification Date: 07/23/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3201 UNIVERSITY DR E STE 150
BRYAN TX
77802-3487
US

IV. Provider business mailing address

511 UNIVERSITY DR E STE 210
COLLEGE STATION TX
77840-1748
US

V. Phone/Fax

Practice location:
  • Phone: 979-777-5545
  • Fax:
Mailing address:
  • Phone: 979-777-5545
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number72142
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number72142
License Number StateTX
# 3
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number72142
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: