Basic Information
| Provider Information | |||||||||
| NPI: | 1841624921 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | FULLER | ||||||||
| FirstName: | KENDRA | ||||||||
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| Credential: | LPC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1600 ALDERSGATE RD | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | LITTLE ROCK | ||||||||
| State: | AR | ||||||||
| PostalCode: | 722056676 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5016610720 | ||||||||
| FaxNumber: | 5013257938 | ||||||||
| Practice Location | |||||||||
| Address1: | 674 ASH FLAT DR | ||||||||
| Address2: | |||||||||
| City: | ASH FLAT | ||||||||
| State: | AR | ||||||||
| PostalCode: | 725139428 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8703451040 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/26/2013 | ||||||||
| LastUpdateDate: | 07/21/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | A1406085 | AR | N | Behavioral Health & Social Service Providers | Counselor | Mental Health | 101YM0800X | P1707336 | AR | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
ID Information
| ID | Type | State | Issuer | Description | 1841624921 | 05 | AR | MEDICAID |