{
"Npi": {
"NPI": "1275936882",
"EntityType": "Organization",
"ReplacementNPI": null,
"EIN": null,
"IsSoleProprietor": null,
"IsOrgSubpart": "N",
"ParentOrgLBN": null,
"ParentOrgTIN": null,
"OrgName": "FULLMER COUNSELING LLC",
"LastName": null,
"FirstName": null,
"MiddleName": null,
"NamePrefix": null,
"NameSuffix": null,
"Credential": null,
"OtherOrgName": null,
"OtherOrgNameTypeCode": null,
"OtherLastName": null,
"OtherFirstName": null,
"OtherMiddleName": null,
"OtherNamePrefix": null,
"OtherNameSuffix": null,
"OtherCredential": null,
"OtherLastNameTypeCode": null,
"FirstLineMailingAddress": "545 SHOUP AVE",
"SecondLineMailingAddress": "SUITE 334",
"MailingAddressCityName": "IDAHO FALLS",
"MailingAddressStateName": "ID",
"MailingAddressPostalCode": "83402-3575",
"MailingAddressCountryCode": "US",
"MailingAddressTelephoneNumber": "208-521-4332",
"MailingAddressFaxNumber": null,
"FirstLinePracticeLocationAddress": "545 SHOUP AVE",
"SecondLinePracticeLocationAddress": "SUITE 334",
"PracticeLocationAddressCityName": "IDAHO FALLS",
"PracticeLocationAddressStateName": "ID",
"PracticeLocationAddressPostalCode": "83402-3575",
"PracticeLocationAddressCountryCode": "US",
"PracticeLocationAddressTelephoneNumber": "208-521-4332",
"PracticeLocationAddressFaxNumber": null,
"EnumerationDate": "09/27/2014",
"LastUpdateDate": "09/27/2014",
"NPIDeactivationReasonCode": null,
"NPIDeactivationReason": null,
"NPIDeactivationDate": null,
"NPIReactivationDate": null,
"GenderCode": null,
"Gender": null,
"AuthorizedOfficialLastName": "FULLMER",
"AuthorizedOfficialFirstName": "NATHAN",
"AuthorizedOfficialMiddleName": null,
"AuthorizedOfficialTitle": "OWNER",
"AuthorizedOfficialNamePrefix": "MR.",
"AuthorizedOfficialNameSuffix": null,
"AuthorizedOfficialCredential": "LCPC",
"AuthorizedOfficialTelephoneNumber": "208-521-4332",
"Taxonomies": {
"Taxonomy": {
"TaxonomyCode": "261QM0801X",
"TaxonomyName": "Mental Health Clinic/Center (Including Community Mental Health Center)",
"LicenseNumber": null,
"LicenseNumberStateCode": null,
"PrimaryTaxonomySwitch": "Y"
}
},
"HealthcareProviderTaxonomyGroups": null
}
}