Healthcare Provider Details

I. General information

NPI: 1952833121
Provider Name (Legal Business Name): KEVIN ANTONIO FULLER M.A., LPC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/28/2017
Last Update Date: 03/28/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

339 MAGIC OAKS CT
SPRING TX
77388-8921
US

IV. Provider business mailing address

339 MAGIC OAKS CT
SPRING TX
77388-8921
US

V. Phone/Fax

Practice location:
  • Phone: 281-389-1117
  • Fax:
Mailing address:
  • Phone: 281-389-1117
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number72905
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: