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General NPI Number Information
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NPI Number | 1346447562
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Entity Type | Individual
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Provider Name | JUDITH CUNNINGHAM FULLER M.S.W., L.C.S.W.
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Gender | Female
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Dates
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Enumeration Date | 06/29/2007
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Last Update Date | 07/08/2007
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Provider Practice Location Address
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Address Line | 10845 OLIVE BLVD SUITE 100
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City | CREVE COEUR
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State | MO
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Zip | 63141-7760
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Country | US
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Telephone | 314-872-3132
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Fax | 314-872-3965
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Provider Business Mailing Address
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Address Line | 10845 OLIVE BLVD SUITE 100
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City | CREVE COEUR
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State | MO
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Zip | 63141-7760
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Country | US
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Telephone | 314-872-3132
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Fax | 314-872-3965
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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 | 1041C0700X
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Taxonomy Name | Clinical Social Worker
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License Number | 001679
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License Number State | MO
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