Individual
MARK P FULLER
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
LCSW, SAC, ICS,
Contact information
Practice address
W3275 WOLF RIVER ROAD, KESHENA, WI 54135
(715) 799-5451
Mailing address
PO BOX 970, KESHENA, WI 54135-0970
(715) 799-5451
Taxonomy
Speciality
Code
Description
License number
State
1041C0700X
Clinical Social Worker
Primary
3082-123
WI
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
39691700
—
WI
Enumeration date
04/29/2008
Last updated
03/18/2016
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