Provider Demographics
NPI:1093534901
Name:FULLER, MADISEN (LCSW)
Entity type:Individual
Prefix:
First Name:MADISEN
Middle Name:
Last Name:FULLER
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:MADISEN
Other - Middle Name:
Other - Last Name:REECE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:16713 DEMI DR
Mailing Address - Street 2:
Mailing Address - City:ATHENS
Mailing Address - State:AL
Mailing Address - Zip Code:35613-6217
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:418 SW 47TH TER
Practice Address - Street 2:
Practice Address - City:CAPE CORAL
Practice Address - State:FL
Practice Address - Zip Code:33914-6506
Practice Address - Country:US
Practice Address - Phone:239-690-6906
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-10-08
Last Update Date:2024-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSW238051041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical