Individual
SHANTEL AZURE FULLER
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
F
Contact information
Practice address
400 NE 7TH ST, GRESHAM, OR 97030-5604
(503) 661-5455
Mailing address
10625 SE 362ND AVE UNIT C8, BORING, OR 97009-9746
(503) 313-6641
Taxonomy
Speciality
Code
Description
License number
State
101YA0400X
Addiction (Substance Use Disorder) Counselor
Primary
—
—
Other
Enumeration date
03/24/2008
Last updated
03/24/2008
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