MEDICARE: SHANEE TREYANA FULLER

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	106S00000X	Behavior Technician

General Provider Information

NPI Number	:	1528530102
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SHANEE TREYANA FULLER

Provider Business Mailing Address
First Line	:	5328 LANIER ISLANDS PKWY UNIT 101
Second Line	:
City	:	BUFORD
State	:	GA
Zip	:	30518-9071
Country	:	US
Telephone Number	:	470-655-1970
Fax Number	:

Provider Business Practice Location Address
First Line	:	5328 LANIER ISLANDS PKWY UNIT 101
Second Line	:
City	:	BUFORD
State	:	GA
Zip	:	30518-9071
Country	:	US
Telephone Number	:	470-655-1970
Fax Number	:

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

Provider Enumeration Date	:	12/20/2018
Last Update Date	:	05/22/2025

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