Provider Demographics
NPI:1114567807
Name:FULLER, TIMOTHY (LMSW-CC)
Entity type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:
Last Name:FULLER
Suffix:
Gender:
Credentials:LMSW-CC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:844 STEVENS AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04103-2676
Mailing Address - Country:US
Mailing Address - Phone:207-505-0227
Mailing Address - Fax:
Practice Address - Street 1:844 STEVENS AVE
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04103-2676
Practice Address - Country:US
Practice Address - Phone:207-505-0227
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-01-09
Last Update Date:2025-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MELC217721041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical