Individual
MRS. TINA JEAN FULLER
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
F
Credential
MS LADC/US
Contact information
Practice address
1101 E MONROE AVE, MCALESTER, OK 74501-4815
(918) 426-7800
Mailing address
3751 WAYSIDE LN, MCALESTER, OK 74501-7643
(918) 329-1476
Taxonomy
Speciality
Code
Description
License number
State
101YA0400X
Addiction (Substance Use Disorder) Counselor
Primary
UNDER SUPERVISON
OK
Other
Enumeration date
11/10/2009
Last updated
10/18/2010
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