Provider Demographics
NPI:1871068643
Name:FULLERTON, ASHLEY MARIE (TLLP)
Entity type:Individual
Prefix:
First Name:ASHLEY
Middle Name:MARIE
Last Name:FULLERTON
Suffix:
Gender:F
Credentials:TLLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:812 E JOLLY RD STE 311
Mailing Address - Street 2:
Mailing Address - City:LANSING
Mailing Address - State:MI
Mailing Address - Zip Code:48910-6825
Mailing Address - Country:US
Mailing Address - Phone:517-346-8275
Mailing Address - Fax:517-346-8291
Practice Address - Street 1:812 E JOLLY RD STE 311
Practice Address - Street 2:
Practice Address - City:LANSING
Practice Address - State:MI
Practice Address - Zip Code:48910-6825
Practice Address - Country:US
Practice Address - Phone:517-346-8275
Practice Address - Fax:517-346-8291
Is Sole Proprietor?:No
Enumeration Date:2018-10-09
Last Update Date:2018-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301017646103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist