Provider Demographics
NPI:1760680474
Name:FULLER, NICOLE L (MA)
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:L
Last Name:FULLER
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:231 S CLOVER DR STE 5
Mailing Address - Street 2:
Mailing Address - City:BAYFIELD
Mailing Address - State:CO
Mailing Address - Zip Code:81122-8833
Mailing Address - Country:US
Mailing Address - Phone:970-769-2435
Mailing Address - Fax:
Practice Address - Street 1:231 S CLOVER DR STE 100
Practice Address - Street 2:
Practice Address - City:BAYFIELD
Practice Address - State:CO
Practice Address - Zip Code:81122-8769
Practice Address - Country:US
Practice Address - Phone:970-769-2435
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-07-03
Last Update Date:2025-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO0006767101YA0400X
CO3031-BHE001101YA0400X
101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)