Provider Demographics
NPI:1427107002
Name:FULLER, BERNITA WYNN (LLPC)
Entity type:Individual
Prefix:
First Name:BERNITA
Middle Name:WYNN
Last Name:FULLER
Suffix:
Gender:F
Credentials:LLPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1303 HORIZON DR
Mailing Address - Street 2:
Mailing Address - City:LAPEER
Mailing Address - State:MI
Mailing Address - Zip Code:48446-8663
Mailing Address - Country:US
Mailing Address - Phone:810-767-5750
Mailing Address - Fax:
Practice Address - Street 1:806 TUURI PL
Practice Address - Street 2:
Practice Address - City:FLINT
Practice Address - State:MI
Practice Address - Zip Code:48503-2465
Practice Address - Country:US
Practice Address - Phone:810-767-5750
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIL928846101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional