MEDICARE: DR. KIMBERLY A FULLER LISW-S

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1041C0700X	Clinical Social Worker	S.1200645	OH

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1083053375
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. KIMBERLY A FULLER LISW-S

Provider Business Mailing Address
First Line	:	3500 LORAIN AVE STE 300
Second Line	:
City	:	CLEVELAND
State	:	OH
Zip	:	44113-3726
Country	:	US
Telephone Number	:	216-250-1607
Fax Number	:	216-304-6669

Provider Business Practice Location Address
First Line	:	3500 LORAIN AVE STE 300
Second Line	:
City	:	CLEVELAND
State	:	OH
Zip	:	44113-3726
Country	:	US
Telephone Number	:	216-250-1607
Fax Number	:	216-304-6669

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/19/2013
Last Update Date	:	08/05/2022

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