Katina Felisa Fuller, DSW, LCSW, CCM

Primary specialty

Clinical Social WorkerTaxonomy code 1041C0700X

License

CSW007891 Issued in GA

Practice address

212 Bonnie Sue Dr
Villa Rica, GA 30180-5517

Phone

(678) 739-8497

NPI assigned

Oct 10, 2023

Sex

Female

Sole proprietor

Yes

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

Specialties & licenses 1

Addresses

Medicare fee-for-service enrollment

Not listed in the public Medicare enrollment file

Medicare enrollment (NPD)

Not enrolled

State licenses

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

{
    "created_epoch": "1696896000000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1696896000000",
    "number": "1598546194",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "212 BONNIE SUE DR",
            "city": "VILLA RICA",
            "state": "GA",
            "postal_code": "301805517",
            "telephone_number": "678-739-8497"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "212 BONNIE SUE DR",
            "city": "VILLA RICA",
            "state": "GA",
            "postal_code": "301805517",
            "telephone_number": "678-739-8497"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "FULLER",
        "first_name": "KATINA",
        "middle_name": "FELISA",
        "name_prefix": "Dr.",
        "credential": "DSW, LCSW, CCM",
        "sole_proprietor": "YES",
        "sex": "F",
        "enumeration_date": "2023-10-10",
        "last_updated": "2023-10-10",
        "certification_date": "2023-10-10",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "1041C0700X",
            "taxonomy_group": "",
            "desc": "Social Worker, Clinical",
            "state": "GA",
            "license": "CSW007891",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

• Fredric a Moore DMD PC
• Kristan Monet Freeman
• Kalyn Friar
• Fruit of My Womb
• Fruits of Labor: Childbirth Education and Breastfeeding Services LLC
• Larry Dewitt Fuller Jr., M.A.
• Sharon Gaiter, OTR/L
• Quencina Gardner, MS, LAPC
• Chandrika Garg, M.D.
• Garner Damian, Inc

• Clinical Social Worker in Villa Rica, GA
• Providers in Villa Rica, GA by specialty
• Clinical Social Worker in Georgia

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Oct 10, 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.