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General NPI Number Information
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NPI Number | 1063230878
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Entity Type | Individual
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Provider Name | MICHAEL FULLER MHPS
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Gender | Male
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Dates
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Enumeration Date | 09/30/2024
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Last Update Date | 04/14/2025
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Provider Practice Location Address
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Address Line | 3008 ROSS AVE STE 100
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City | DALLAS
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State | TX
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Zip | 75204-5519
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Country | US
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Telephone | 682-277-9994
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Fax |
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Provider Business Mailing Address
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Address Line | 5900 BALCONES DR STE 100
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City | AUSTIN
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State | TX
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Zip | 78731-4298
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Country | US
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Telephone | 682-277-9994
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 175T00000X
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Taxonomy Name | Peer Specialist
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License Number | 2076-0624
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License Number State | TX
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