Provider Demographics
NPI:1215462718
Name:FULLER, PAGRITA COMPAGARIS (MSW, LCSW)
Entity type:Individual
Prefix:MRS
First Name:PAGRITA
Middle Name:COMPAGARIS
Last Name:FULLER
Suffix:
Gender:F
Credentials:MSW, LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2669 LANTERN TRL
Mailing Address - Street 2:
Mailing Address - City:LITHIA SPRINGS
Mailing Address - State:GA
Mailing Address - Zip Code:30122-2792
Mailing Address - Country:US
Mailing Address - Phone:936-676-7760
Mailing Address - Fax:
Practice Address - Street 1:8335 OFFICE PARK DR
Practice Address - Street 2:
Practice Address - City:DOUGLASVILLE
Practice Address - State:GA
Practice Address - Zip Code:30134-6937
Practice Address - Country:US
Practice Address - Phone:678-324-0476
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-04-22
Last Update Date:2017-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GACSW0060341041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
GACSW006043OtherGA COMPOSITE BOARD OF PC, SW,, AND MFT
GAMSW005939OtherGEORGIA COMPOSITE BOARD OF PC, SW, AND MFT