Provider Demographics
NPI:1306897467
Name:FULLMER, ANNA R (MSSW, LCSW)
Entity type:Individual
Prefix:
First Name:ANNA
Middle Name:R
Last Name:FULLMER
Suffix:
Gender:F
Credentials:MSSW, LCSW
Other - Prefix:
Other - First Name:BARBARA
Other - Middle Name:J
Other - Last Name:FULLMER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MSSW, LCSW
Mailing Address - Street 1:400 S TOWNLINE RD
Mailing Address - Street 2:
Mailing Address - City:WAUTOMA
Mailing Address - State:WI
Mailing Address - Zip Code:54982-6922
Mailing Address - Country:US
Mailing Address - Phone:920-787-5514
Mailing Address - Fax:
Practice Address - Street 1:400 S TOWNLINE RD
Practice Address - Street 2:
Practice Address - City:WAUTOMA
Practice Address - State:WI
Practice Address - Zip Code:54982-6922
Practice Address - Country:US
Practice Address - Phone:920-787-5514
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-13
Last Update Date:2024-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI6573-1231041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI39797500Medicaid
S89674Medicare UPIN
002700486Medicare ID - Type Unspecified