Provider Demographics
NPI:1457699969
Name:FULLER, ELISE J (MA, LPC)
Entity type:Individual
Prefix:
First Name:ELISE
Middle Name:J
Last Name:FULLER
Suffix:
Gender:F
Credentials:MA, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16610 DALLAS PKWY
Mailing Address - Street 2:SUITE 2100
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75248-2617
Mailing Address - Country:US
Mailing Address - Phone:972-733-3988
Mailing Address - Fax:972-733-3923
Practice Address - Street 1:16610 DALLAS PKWY
Practice Address - Street 2:SUITE 2100
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75248-2617
Practice Address - Country:US
Practice Address - Phone:972-733-3988
Practice Address - Fax:972-733-3923
Is Sole Proprietor?:No
Enumeration Date:2013-01-18
Last Update Date:2014-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX69467101Y00000X, 101YM0800X, 101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health