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General NPI Number Information
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NPI Number | 1497543102
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Entity Type | Individual
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Provider Name | BETHANY RAE FULLER LPC
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Gender | Female
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Dates
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Enumeration Date | 04/30/2025
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Last Update Date | 04/30/2025
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Provider Practice Location Address
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Address Line | 260 CLARKSON RD
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City | ELLISVILLE
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State | MO
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Zip | 63011-2245
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Country | US
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Telephone | 314-254-3448
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Fax |
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Provider Business Mailing Address
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Address Line | 3931 WYOMING ST
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City | SAINT LOUIS
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State | MO
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Zip | 63116-3917
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Country | US
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Telephone | 312-505-8141
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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 | 101YM0800X
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Taxonomy Name | Mental Health Counselor
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License Number | 2022003037
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License Number State | MO
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