Basic Information
| Provider Information | |||||||||
| NPI: | 1811395411 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | FULLER | ||||||||
| FirstName: | ANGELA | ||||||||
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| Credential: | MS, CPC-I | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1041 WARWICK AVE | ||||||||
| Address2: | |||||||||
| City: | FALLON | ||||||||
| State: | NV | ||||||||
| PostalCode: | 894063662 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8018753055 | ||||||||
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| Practice Location | |||||||||
| Address1: | 850 MILL ST STE 100 | ||||||||
| Address2: | |||||||||
| City: | RENO | ||||||||
| State: | NV | ||||||||
| PostalCode: | 895021463 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7755386700 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 12/12/2014 | ||||||||
| LastUpdateDate: | 03/17/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | N | Behavioral Health & Social Service Providers | Counselor | Mental Health | 101YM0800X | CI0284 | NV | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
No ID Information.