Provider Demographics
NPI:1720950777
Name:FULLER, RAQUEL
Entity type:Individual
Prefix:
First Name:RAQUEL
Middle Name:
Last Name:FULLER
Suffix:
Gender:X
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1185 KING ST APT A
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:SC
Mailing Address - Zip Code:29403-3267
Mailing Address - Country:US
Mailing Address - Phone:301-704-0777
Mailing Address - Fax:
Practice Address - Street 1:186 SEVEN FARMS DR STE F
Practice Address - Street 2:
Practice Address - City:DANIEL ISLAND
Practice Address - State:SC
Practice Address - Zip Code:29492-8522
Practice Address - Country:US
Practice Address - Phone:803-814-3812
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-09-19
Last Update Date:2025-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Single Specialty