Provider Demographics
NPI:1194575969
Name:MANIGO FULLER, SOPHIE
Entity type:Individual
Prefix:
First Name:SOPHIE
Middle Name:
Last Name:MANIGO FULLER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:26 LEONE AVE
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29617-3932
Mailing Address - Country:US
Mailing Address - Phone:864-551-5763
Mailing Address - Fax:
Practice Address - Street 1:45 CREEKVIEW CT
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:SC
Practice Address - Zip Code:29615-4800
Practice Address - Country:US
Practice Address - Phone:864-609-4108
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-03-25
Last Update Date:2024-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician