Provider Demographics
NPI:1700767969
Name:FULLER, CECELIA (LLMSW)
Entity type:Individual
Prefix:
First Name:CECELIA
Middle Name:
Last Name:FULLER
Suffix:
Gender:F
Credentials:LLMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13150 SPRUCE RIDGE RD
Mailing Address - Street 2:
Mailing Address - City:GOWEN
Mailing Address - State:MI
Mailing Address - Zip Code:49326-9566
Mailing Address - Country:US
Mailing Address - Phone:517-303-0373
Mailing Address - Fax:
Practice Address - Street 1:118 S GREENVILLE WEST DR STE B
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:MI
Practice Address - Zip Code:48838-3554
Practice Address - Country:US
Practice Address - Phone:616-805-3660
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-09-11
Last Update Date:2025-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6851119228104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker