Provider Demographics
NPI:1538257928
Name:FULLER, EMMETT FRAZER (MA, LPC)
Entity type:Individual
Prefix:
First Name:EMMETT
Middle Name:FRAZER
Last Name:FULLER
Suffix:
Gender:M
Credentials:MA, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:899 BURNS DR SE
Mailing Address - Street 2:
Mailing Address - City:MARIETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30067-7111
Mailing Address - Country:US
Mailing Address - Phone:770-321-3424
Mailing Address - Fax:770-321-2479
Practice Address - Street 1:122 CHERRY ST NE
Practice Address - Street 2:
Practice Address - City:MARIETTA
Practice Address - State:GA
Practice Address - Zip Code:30060-7206
Practice Address - Country:US
Practice Address - Phone:770-427-2911
Practice Address - Fax:770-321-2479
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA001674101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA11538751OtherAETNA PROVIDER NUMBER