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General NPI Number Information
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NPI Number | 1275936882
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Entity Type | Organization
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Legal Business Name | FULLMER COUNSELING LLC
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Dates
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Enumeration Date | 09/27/2014
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Last Update Date | 09/27/2014
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Provider Practice Location Address
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Address Line | 545 SHOUP AVE SUITE 334
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City | IDAHO FALLS
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State | ID
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Zip | 83402-3575
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Country | US
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Telephone | 208-521-4332
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Fax |
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Provider Business Mailing Address
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Address Line | 545 SHOUP AVE SUITE 334
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City | IDAHO FALLS
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State | ID
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Zip | 83402-3575
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Country | US
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Telephone | 208-521-4332
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | MR. NATHAN FULLMER
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Credential | LCPC
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Telephone | 208-521-4332
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QM0801X
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Taxonomy Name | Mental Health Clinic/Center (Including Community Mental Health Center)
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License Number |
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License Number State |
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