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General NPI Number Information
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NPI Number | 1952712002
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Entity Type | Individual
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Provider Name | LAURINA D FULLAM LADC, LCMHC
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Gender | Female
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Dates
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Enumeration Date | 05/12/2014
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Last Update Date | 11/03/2023
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Provider Practice Location Address
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Address Line | 3333 S CONGRESS AVE
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City | DELRAY BEACH
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State | FL
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Zip | 33445-7308
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Country | US
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Telephone | 844-309-9543
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX G
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City | RANDOLPH
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State | VT
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Zip | 05060-0167
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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 | 101YM0800X
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Taxonomy Name | Mental Health Counselor
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 101YA0400X
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Taxonomy Name | Addiction (Substance Use Disorder) Counselor
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License Number | 000625
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License Number State | VT
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