Provider Demographics
NPI:1053000232
Name:FULL CUP LLC
Entity type:Organization
Organization Name:FULL CUP LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:JESSICA
Authorized Official - Middle Name:
Authorized Official - Last Name:ROUSSELLE
Authorized Official - Suffix:
Authorized Official - Credentials:LICSW
Authorized Official - Phone:857-293-1447
Mailing Address - Street 1:6 LYNDE ST STE LL-C
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:MA
Mailing Address - Zip Code:01970-3404
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6 LYNDE ST STE LL-C
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:MA
Practice Address - Zip Code:01970-3404
Practice Address - Country:US
Practice Address - Phone:857-293-1447
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-05-03
Last Update Date:2023-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty