MEDICARE: MRS. MEGAN FULLEN 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	0904007263	VA

General Provider Information

NPI Number	:	1922319789
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. MEGAN FULLEN LCSW

Provider Business Mailing Address
First Line	:	4820 PINEY BRANCH RD
Second Line	:
City	:	FAIRFAX
State	:	VA
Zip	:	22030-6233
Country	:	US
Telephone Number	:	703-266-2694
Fax Number	:

Provider Business Practice Location Address
First Line	:	14377 HEREFORD RD
Second Line	:
City	:	WOODBRIDGE
State	:	VA
Zip	:	22193-2107
Country	:	US
Telephone Number	:	703-878-6670
Fax Number	:	703-878-3370

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

Provider Enumeration Date	:	06/27/2010
Last Update Date	:	06/02/2021

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