Xavier Quamaine Lee Fullerton, LPC-A, CRC

Primary specialty

Mental Health CounselorTaxonomy code 101YM0800X

License

14556 Issued in NC

Practice address

140 Kimel Park Dr Ste 101
Winston Salem, NC 27103-6185

Phone

(336) 718-7280

Fax

(336) 718-7290

NPI assigned

Apr 10, 2019

Sex

Male

Sole proprietor

No

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 3

Addresses

Medicare fee-for-service enrollment

Not listed in the public Medicare enrollment file

Medicare enrollment (NPD)

Enrolled

State licenses

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1554854400000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1692748800000",
    "number": "1215490966",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "PO BOX 60447",
            "city": "CHARLOTTE",
            "state": "NC",
            "postal_code": "282600447"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "140 KIMEL PARK DR STE 101",
            "city": "WINSTON SALEM",
            "state": "NC",
            "postal_code": "271036185",
            "telephone_number": "336-718-7280",
            "fax_number": "336-718-7290"
        }
    ],
    "practiceLocations": [
        {
            "address_1": "120 Health Center Dr",
            "address_purpose": "LOCATION",
            "city": "Ahoskie",
            "state": "NC",
            "postal_code": "279108161",
            "country_code": "US",
            "telephone_number": "252-332-3548",
            "fax_number": "252-332-1665",
            "country_name": "United States",
            "address_type": "DOM"
        }
    ],
    "basic": {
        "last_name": "FULLERTON",
        "first_name": "XAVIER",
        "middle_name": "QUAMAINE LEE",
        "credential": "LPC-A, CRC",
        "sole_proprietor": "NO",
        "sex": "M",
        "enumeration_date": "2019-04-10",
        "last_updated": "2023-08-23",
        "certification_date": "2023-08-23",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "101YP2500X",
            "taxonomy_group": "",
            "desc": "Counselor, Professional",
            "state": "NC",
            "license": "A14556",
            "primary": false
        },
        {
            "code": "225C00000X",
            "taxonomy_group": "",
            "desc": "Rehabilitation Counselor",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "101YM0800X",
            "taxonomy_group": "",
            "desc": "Counselor, Mental Health",
            "state": "NC",
            "license": "14556",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

• Lynn Fullenkamp
• Emily West Fuller, NP-C
• Marsha Fuller, PHARMD
• Perla Jamilette Fuller, MSW, LCSW
• Stanley Brian Fuller, M.D.
• Denise V Fulller
• Fulp Therapy Services, Inc.
• Andrew G Fulp, PA-C
• Nanette Nicole Fulp, PA-C
• Juwan Fulton

• Mental Health Counselor in Winston Salem, NC
• Providers in Winston Salem, NC by specialty
• Mental Health Counselor in North Carolina

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Aug 23, 2023; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.