Provider Demographics
NPI:1447124151
Name:FULLER, SOPHIA DANIELLE
Entity type:Individual
Prefix:
First Name:SOPHIA
Middle Name:DANIELLE
Last Name:FULLER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6305 SALAMANDER RUN LN
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28215-5084
Mailing Address - Country:US
Mailing Address - Phone:704-804-0291
Mailing Address - Fax:
Practice Address - Street 1:7160 WEDDINGTON RD NW STE 144
Practice Address - Street 2:
Practice Address - City:CONCORD
Practice Address - State:NC
Practice Address - Zip Code:28027-3676
Practice Address - Country:US
Practice Address - Phone:980-777-1652
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-10-03
Last Update Date:2025-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCP0224421041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical