Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 101YP2500X | Professional Counselor | A14556 | NC |
N | 225C00000X | Rehabilitation Counselor |
NPI | 1215490966 |
---|---|
Provider Name | Xavier Fullerton |
First Address | Ahoskie, NC 27910-0669 |
Second Address | Ahoskie, NC 27910-8161 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 10/04/2019 |
Last Update Date | 10/04/2019 |