=====================================================
General NPI Number Information
=====================================================
NPI Number | 1700767969
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | CECELIA FULLER LLMSW
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/11/2025
-----------------------------------------------------
Last Update Date | 09/11/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 118 S GREENVILLE WEST DR STE B
-----------------------------------------------------
City | GREENVILLE
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48838-3554
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 616-805-3660
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 13150 SPRUCE RIDGE RD
-----------------------------------------------------
City | GOWEN
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 49326-9566
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 517-303-0373
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 104100000X
-----------------------------------------------------
Taxonomy Name | Social Worker
-----------------------------------------------------
License Number | 6851119228
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------