Provider Demographics
NPI:1982442778
Name:FULLER, HERBERT BETANGA
Entity type:Individual
Prefix:
First Name:HERBERT
Middle Name:BETANGA
Last Name:FULLER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6817 STORCH CT
Mailing Address - Street 2:
Mailing Address - City:LANHAM
Mailing Address - State:MD
Mailing Address - Zip Code:20706-2189
Mailing Address - Country:US
Mailing Address - Phone:202-528-7523
Mailing Address - Fax:
Practice Address - Street 1:6817 STORCH CT
Practice Address - Street 2:
Practice Address - City:LANHAM
Practice Address - State:MD
Practice Address - Zip Code:20706-2189
Practice Address - Country:US
Practice Address - Phone:202-528-7523
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-07-17
Last Update Date:2024-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No171M00000XOther Service ProvidersCase Manager/Care Coordinator