Healthcare Provider Details

I. General information

NPI: 1023440377
Provider Name (Legal Business Name): JOAN N FULLER MA, LPC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/08/2013
Last Update Date: 10/12/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

901 4TH ST SUITE 160
HUDSON WI
54016-1681
US

IV. Provider business mailing address

1497 MALLARD AVE
BALDWIN WI
54002-5561
US

V. Phone/Fax

Practice location:
  • Phone: 763-210-9966
  • Fax: 763-210-6886
Mailing address:
  • Phone: 651-329-9112
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: