| Doctor Name: | DR. MICKEY JOE FULLER |
| NPI Number: | 1427017573 |
| Entity Type Code: | Individual (1) |
| Gender: | M |
| Credentials: | MA, MS, PSY.D. |
| License Number: | 5329261-6006 |
| Business Practice Address: | 198 E Center St Moab, UT - 845322430 |
| Business Phone Number: | 4352596131 |
| Business Fax Number: | 4352595369 |
| Mailing Address: | 3310 Spanish Valley Dr, MOAB |
| State: | UT |
| Postal Code: | 845323636 |
| Phone Number: | 8019533113 |
| Fax Number: | |
| NPI Enumeration Date: | 03/18/2006 |
| NPI Last Update Date: | 11/09/2009 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 101YA0400X |
| License Number: | 5329261-6006 |
| Healthcare Provider Taxonomy: (Secondary) | N |
| State: | UT |
| Taxonomy Type: | Behavioral Health & Social Service Providers |
| Taxonomy Classification: | Counselor |
| Taxonomy Specialization: | Addiction (Substance Use Disorder) |
| Taxonomy Definition: | |