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General NPI Number Information
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NPI Number | 1700209327
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Entity Type | Individual
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Provider Name | LARRY DEWITT FULLER JR. M.A.
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Gender | Male
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Dates
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Enumeration Date | 02/03/2014
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Last Update Date | 02/03/2014
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Provider Practice Location Address
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Address Line | 307 OLD STONE RD
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City | VILLA RICA
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State | GA
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Zip | 30180-1214
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Country | US
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Telephone | 770-459-8799
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Fax |
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Provider Business Mailing Address
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Address Line | 6439 BRIARWOOD CT
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City | RIVERDALE
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State | GA
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Zip | 30296-2904
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Country | US
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Telephone | 404-433-0307
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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 | 101YP2500X
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Taxonomy Name | Professional Counselor
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License Number | LPC007525
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License Number State | GA
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