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General NPI Number Information
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NPI Number | 1366934861
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Entity Type | Individual
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Provider Name | SCOTT LEE FULLER
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Gender | Male
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Dates
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Enumeration Date | 05/31/2018
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Last Update Date | 06/20/2018
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Provider Practice Location Address
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Address Line | 241 SUMMIT AVE STE 100
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City | GREENSBORO
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State | NC
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Zip | 27401-3017
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Country | US
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Telephone | 336-965-7369
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Fax |
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Provider Business Mailing Address
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Address Line | 305 KING ST APT 3A
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City | GREENSBORO
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State | NC
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Zip | 27406-1696
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Country | US
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Telephone |
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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 | 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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