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General NPI Number Information
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NPI Number | 1215335674
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Entity Type | Organization
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Legal Business Name | FULLER LIVING & ASSOCIATES, LLC
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Dates
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Enumeration Date | 12/16/2014
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Last Update Date | 09/02/2016
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Provider Practice Location Address
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Address Line | 10077 DOGWOOD ST NW STE 206
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City | COON RAPIDS
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State | MN
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Zip | 55448
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Country | US
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Telephone | 763-647-8188
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Fax |
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Provider Business Mailing Address
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Address Line | 7700 SUNWOOD DR NW 114
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City | RAMSEY
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State | MN
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Zip | 55303
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Country | US
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Telephone | 763-647-8188
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Fax |
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Authorized Official
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Title or Position | LMFT/PRESIDENT
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Name | AMBER ROSE FULLER
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Credential |
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Telephone | 763-647-8188
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 251S00000X
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Taxonomy Name | Community/Behavioral Health Agency
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License Number |
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License Number State |
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