MEDICARE: MADISEN FULLER LCSW

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	SW23805	FL

General Provider Information

NPI Number	:	1093534901
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MADISEN FULLER LCSW

Provider Business Mailing Address
First Line	:	16713 DEMI DR
Second Line	:
City	:	ATHENS
State	:	AL
Zip	:	35613-6217
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	418 SW 47TH TER
Second Line	:
City	:	CAPE CORAL
State	:	FL
Zip	:	33914-6506
Country	:	US
Telephone Number	:	239-690-6906
Fax Number	:

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

Provider Enumeration Date	:	10/08/2024
Last Update Date	:	11/05/2024

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