Mark P Fuller, LCSW, SAC, ICS,

Primary specialty

Clinical Social WorkerTaxonomy code 1041C0700X

License

3082-123 Issued in WI

Practice address

W3275 Wolf River Road
Keshena, WI 54135

Phone

(715) 799-5451

NPI assigned

Apr 29, 2008

Sex

Male

Sole proprietor

No

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

Specialties & licenses 1

Addresses

Other identifiers 1

Medicare fee-for-service enrollment

Not listed in the public Medicare enrollment file

Medicare enrollment (NPD)

Enrolled

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

{
    "created_epoch": "1209427200000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1458259200000",
    "number": "1780859744",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "PO BOX 970",
            "city": "KESHENA",
            "state": "WI",
            "postal_code": "541350970",
            "telephone_number": "715-799-5451"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "W3275 WOLF RIVER ROAD",
            "city": "KESHENA",
            "state": "WI",
            "postal_code": "54135",
            "telephone_number": "715-799-5451"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "FULLER",
        "first_name": "MARK",
        "middle_name": "P",
        "credential": "LCSW, SAC, ICS,",
        "sole_proprietor": "NO",
        "sex": "M",
        "enumeration_date": "2008-04-29",
        "last_updated": "2016-03-18",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "1041C0700X",
            "taxonomy_group": "",
            "desc": "Social Worker, Clinical",
            "state": "WI",
            "license": "3082-123",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "39691700",
            "state": "WI"
        }
    ],
    "endpoints": [],
    "other_names": []
}

• Sarah Dittman, RDH
• Kiersten Ann Fischer, APSW
• Ryan Forbey, LPC
• Carol J Foss, PH D
• Ronald D Freeman, D.M.D.
• Beth L Gillis, MD
• Joseph E Guenther, M.D.
• Holly Ann Gumieny
• Sarah Harkey, APNP
• Diane Marie Hietpas, MA, SAC

• Clinical Social Worker in Keshena, WI
• Providers in Keshena, WI by specialty
• Clinical Social Worker in Wisconsin

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Mar 18, 2016; 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.