Provider Demographics
NPI:1538219076
Name:FULLER, SHEILA P (MCD,CCC-SLP)
Entity type:Individual
Prefix:MRS
First Name:SHEILA
Middle Name:P
Last Name:FULLER
Suffix:
Gender:F
Credentials:MCD,CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:120 BRICKSTONE PL
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:AL
Mailing Address - Zip Code:35756-3498
Mailing Address - Country:US
Mailing Address - Phone:256-617-0203
Mailing Address - Fax:
Practice Address - Street 1:103 INTERCOM DR
Practice Address - Street 2:SUITE C
Practice Address - City:MADISON
Practice Address - State:AL
Practice Address - Zip Code:35758-2640
Practice Address - Country:US
Practice Address - Phone:256-464-9464
Practice Address - Fax:256-325-9469
Is Sole Proprietor?:No
Enumeration Date:2007-01-10
Last Update Date:2021-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL2301235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL51536066OtherBLUE CROSS BLUE SHIELD
AL890017370Medicaid
AL870757392OtherTRICARE SOUTH REGION