Provider Demographics
NPI:1871614115
Name:FULLER, KELLY SUE (LPC)
Entity type:Individual
Prefix:MRS
First Name:KELLY
Middle Name:SUE
Last Name:FULLER
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:310 FLAX MILL WAY
Mailing Address - Street 2:
Mailing Address - City:CHESAPEAKE
Mailing Address - State:VA
Mailing Address - Zip Code:23322-5893
Mailing Address - Country:US
Mailing Address - Phone:757-419-1726
Mailing Address - Fax:757-419-1726
Practice Address - Street 1:1545 CROSSWAYS BLVD STE 250
Practice Address - Street 2:
Practice Address - City:CHESAPEAKE
Practice Address - State:VA
Practice Address - Zip Code:23320-0218
Practice Address - Country:US
Practice Address - Phone:757-419-1726
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-03
Last Update Date:2024-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC4184101YP2500X
VA0701003292101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional