Provider Demographics
NPI:1215490966
Name:FULLERTON, XAVIER QUAMAINE LEE (LPC-A, CRC)
Entity type:Individual
Prefix:
First Name:XAVIER
Middle Name:QUAMAINE LEE
Last Name:FULLERTON
Suffix:
Gender:M
Credentials:LPC-A, CRC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 60447
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28260-0447
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:140 KIMEL PARK DR STE 101
Practice Address - Street 2:
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27103-6185
Practice Address - Country:US
Practice Address - Phone:336-718-7280
Practice Address - Fax:336-718-7290
Is Sole Proprietor?:No
Enumeration Date:2019-04-10
Last Update Date:2023-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCA14556101YP2500X
225C00000X
NC14556101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No225C00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Counselor