Provider Demographics
NPI:1699115139
Name:FULLER, STEVEN MICHAEL (LPC, LMFT)
Entity type:Individual
Prefix:MR
First Name:STEVEN
Middle Name:MICHAEL
Last Name:FULLER
Suffix:
Gender:M
Credentials:LPC, LMFT
Other - Prefix:MR
Other - First Name:S.
Other - Middle Name:MICHAEL
Other - Last Name:FULLER
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MED
Mailing Address - Street 1:PO BOX 655
Mailing Address - Street 2:
Mailing Address - City:ANADARKO
Mailing Address - State:OK
Mailing Address - Zip Code:73005-0655
Mailing Address - Country:US
Mailing Address - Phone:580-585-3346
Mailing Address - Fax:
Practice Address - Street 1:4202 SW LEE BLVD.
Practice Address - Street 2:PARK RIDGE PROFESSIONAL CENTER
Practice Address - City:LAWTON
Practice Address - State:OK
Practice Address - Zip Code:73505
Practice Address - Country:US
Practice Address - Phone:580-585-3346
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-06-28
Last Update Date:2013-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK200101YP2500X
OK88106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist