Provider Demographics
NPI:1366601304
Name:FULLER, TERRI A (LCPC)
Entity type:Individual
Prefix:
First Name:TERRI
Middle Name:A
Last Name:FULLER
Suffix:
Gender:F
Credentials:LCPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1016 S MADISON ST
Mailing Address - Street 2:SUITE A
Mailing Address - City:DU QUOIN
Mailing Address - State:IL
Mailing Address - Zip Code:62832-2442
Mailing Address - Country:US
Mailing Address - Phone:618-542-4357
Mailing Address - Fax:618-542-3442
Practice Address - Street 1:1016 S MADISON ST
Practice Address - Street 2:SUITE A
Practice Address - City:DU QUOIN
Practice Address - State:IL
Practice Address - Zip Code:62832-2442
Practice Address - Country:US
Practice Address - Phone:618-542-4357
Practice Address - Fax:618-542-3442
Is Sole Proprietor?:No
Enumeration Date:2008-06-05
Last Update Date:2008-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL180-004047101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional