Provider Demographics
NPI:1144981887
Name:FULLER, CHARIDITH (MS)
Entity type:Individual
Prefix:
First Name:CHARIDITH
Middle Name:
Last Name:FULLER
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2708 BRYANT DR SW
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:TN
Mailing Address - Zip Code:37311-0824
Mailing Address - Country:US
Mailing Address - Phone:810-623-5450
Mailing Address - Fax:
Practice Address - Street 1:391 BROAD ST. SW
Practice Address - Street 2:STE 202
Practice Address - City:CLEVELAND
Practice Address - State:TN
Practice Address - Zip Code:37311
Practice Address - Country:US
Practice Address - Phone:423-641-1105
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-01-05
Last Update Date:2022-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN1936106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist