Basic Information
| Provider Information | |||||||||
| NPI: | 1548410244 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | FULLENKAMP | ||||||||
| FirstName: | SHELLEY | ||||||||
| MiddleName: | S | ||||||||
| NamePrefix: | MISS | ||||||||
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| Credential: | LSW, LPC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4761 STATE ROUTE 29 | ||||||||
| Address2: | |||||||||
| City: | CELINA | ||||||||
| State: | OH | ||||||||
| PostalCode: | 458228216 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4195841000 | ||||||||
| FaxNumber: | 4195841825 | ||||||||
| Practice Location | |||||||||
| Address1: | 4761 STATE ROUTE 29 | ||||||||
| Address2: | |||||||||
| City: | CELINA | ||||||||
| State: | OH | ||||||||
| PostalCode: | 458228216 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4195841000 | ||||||||
| FaxNumber: | 4195841825 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/30/2008 | ||||||||
| LastUpdateDate: | 09/21/2012 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YP2500X | C. 0027325 | OH | Y | Behavioral Health & Social Service Providers | Counselor | Professional | 104100000X | S. 0027325 | OH | N | Behavioral Health & Social Service Providers | Social Worker |
No ID Information.