Provider Demographics
NPI:1497543102
Name:FULLER, BETHANY RAE (LPC)
Entity type:Individual
Prefix:
First Name:BETHANY
Middle Name:RAE
Last Name:FULLER
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3931 WYOMING ST
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63116-3917
Mailing Address - Country:US
Mailing Address - Phone:312-505-8141
Mailing Address - Fax:
Practice Address - Street 1:260 CLARKSON RD
Practice Address - Street 2:
Practice Address - City:ELLISVILLE
Practice Address - State:MO
Practice Address - Zip Code:63011-2245
Practice Address - Country:US
Practice Address - Phone:314-254-3448
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-04-30
Last Update Date:2025-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2022003037101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health