Provider Demographics
NPI:1992356448
Name:FULLERTON, TAYNA (LLBSW)
Entity type:Individual
Prefix:
First Name:TAYNA
Middle Name:
Last Name:FULLERTON
Suffix:
Gender:F
Credentials:LLBSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:621 W OLDFIELD ST APT 1
Mailing Address - Street 2:
Mailing Address - City:ALPENA
Mailing Address - State:MI
Mailing Address - Zip Code:49707-1876
Mailing Address - Country:US
Mailing Address - Phone:313-829-2191
Mailing Address - Fax:
Practice Address - Street 1:400 JOHNSON ST
Practice Address - Street 2:
Practice Address - City:ALPENA
Practice Address - State:MI
Practice Address - Zip Code:49707-1434
Practice Address - Country:US
Practice Address - Phone:989-356-2161
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-09-26
Last Update Date:2019-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6802090619104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker