MEDICARE: FULLER & ASSOCIATES, LLC

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	261QM0855X	Adolescent and Children Mental Health Clinic/Center

General Provider Information

NPI Number	:	1114426400
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	FULLER & ASSOCIATES, LLC

Provider Business Mailing Address
First Line	:	1743 GAY DR
Second Line	:
City	:	ORLANDO
State	:	FL
Zip	:	32803-1914
Country	:	US
Telephone Number	:	407-716-7669
Fax Number	:	407-641-9615

Provider Business Practice Location Address
First Line	:	1743 GAY DR
Second Line	:
City	:	ORLANDO
State	:	FL
Zip	:	32803-1914
Country	:	US
Telephone Number	:	407-716-7669
Fax Number	:	407-641-9615

Authorized Official
Title or Position	:	OWNER
Name	:	MICHAEL FULLER
Credential	:	MS
Telephone Number	:	407-716-7669

Provider Enumeration Date	:	02/02/2018
Last Update Date	:	02/02/2018

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Directions to “FULLER & ASSOCIATES, LLC ” Practice Location

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