Provider Demographics
NPI:1245847607
Name:FULLER, OLANDO WAYNE (QMHP)
Entity type:Individual
Prefix:
First Name:OLANDO
Middle Name:WAYNE
Last Name:FULLER
Suffix:
Gender:M
Credentials:QMHP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2605 EAGLE ROCK CT
Mailing Address - Street 2:
Mailing Address - City:CHESTER
Mailing Address - State:VA
Mailing Address - Zip Code:23831-7051
Mailing Address - Country:US
Mailing Address - Phone:804-253-7075
Mailing Address - Fax:
Practice Address - Street 1:2605 EAGLE ROCK CT
Practice Address - Street 2:
Practice Address - City:CHESTER
Practice Address - State:VA
Practice Address - Zip Code:23831-7051
Practice Address - Country:US
Practice Address - Phone:804-253-7075
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-29
Last Update Date:2020-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0732006726106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician