Provider Demographics
NPI:1447649546
Name:FULLEN, DAVID (LMFT)
Entity type:Individual
Prefix:
First Name:DAVID
Middle Name:
Last Name:FULLEN
Suffix:
Gender:M
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7428 HIGHLAND LICK RD
Mailing Address - Street 2:
Mailing Address - City:ELKTON
Mailing Address - State:KY
Mailing Address - Zip Code:42220-8926
Mailing Address - Country:US
Mailing Address - Phone:270-445-0330
Mailing Address - Fax:
Practice Address - Street 1:7428 HIGHLAND LICK RD
Practice Address - Street 2:
Practice Address - City:ELKTON
Practice Address - State:KY
Practice Address - Zip Code:42220-8926
Practice Address - Country:US
Practice Address - Phone:270-445-0330
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-01-13
Last Update Date:2015-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY0718106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist