Individual
EMMETT FRAZER FULLER
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Credential
MA, LPC
Contact information
Practice address
122 CHERRY ST NE, MARIETTA, GA 30060-7206
(770) 427-2911
(770) 321-2479
Mailing address
899 BURNS DR SE, MARIETTA, GA 30067-7111
(770) 321-3424
(770) 321-2479
Taxonomy
Speciality
Code
Description
License number
State
101YP2500X
Professional Counselor
Primary
001674
GA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
11538751
AETNA PROVIDER NUMBER
GA
Enumeration date
10/11/2006
Last updated
07/08/2007
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