=====================================================
General NPI Number Information
=====================================================
NPI Number | 1710310107
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | RASHARA NICHOLE FULLER PH.D.
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/21/2013
-----------------------------------------------------
Last Update Date | 03/27/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 50 NEPTUNE BLVD 692
-----------------------------------------------------
City | NEPTUNE
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07753-0775
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 908-202-1467
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 50 NEPTUNE BLVD 692
-----------------------------------------------------
City | NEPTUNE
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07753-3610
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 908-202-1467
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101Y00000X
-----------------------------------------------------
Taxonomy Name | Counselor
-----------------------------------------------------
License Number | 37PC00710500
-----------------------------------------------------
License Number State | NJ
-----------------------------------------------------