Provider Demographics
NPI:1396123196
Name:FULLERTON, SUSAN PATRICIA (LPCC)
Entity type:Individual
Prefix:MRS
First Name:SUSAN
Middle Name:PATRICIA
Last Name:FULLERTON
Suffix:
Gender:F
Credentials:LPCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:830 BOONE AVE N
Mailing Address - Street 2:
Mailing Address - City:GOLDEN VALLEY
Mailing Address - State:MN
Mailing Address - Zip Code:55427-4568
Mailing Address - Country:US
Mailing Address - Phone:763-331-3033
Mailing Address - Fax:763-331-3039
Practice Address - Street 1:2060 CENTRE POINTE BLVD
Practice Address - Street 2:
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55120-1269
Practice Address - Country:US
Practice Address - Phone:651-774-0011
Practice Address - Fax:651-774-0606
Is Sole Proprietor?:No
Enumeration Date:2015-05-12
Last Update Date:2015-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNCC00976101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional