Provider Demographics
NPI:1083084115
Name:FULLER, MICHAEL CHARLES JR
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:CHARLES
Last Name:FULLER
Suffix:JR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1076 SANTO ANTONIO DR
Mailing Address - Street 2:
Mailing Address - City:COLTON
Mailing Address - State:CA
Mailing Address - Zip Code:92324-8103
Mailing Address - Country:US
Mailing Address - Phone:909-433-9824
Mailing Address - Fax:
Practice Address - Street 1:1076 SANTO ANTONIO DR
Practice Address - Street 2:
Practice Address - City:COLTON
Practice Address - State:CA
Practice Address - Zip Code:92324-8103
Practice Address - Country:US
Practice Address - Phone:909-433-9824
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-10-01
Last Update Date:2024-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA17771101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)