Provider Demographics
NPI:1679746648
Name:FULLER, SLOAN CLARE (LCPC)
Entity type:Individual
Prefix:
First Name:SLOAN
Middle Name:CLARE
Last Name:FULLER
Suffix:
Gender:F
Credentials:LCPC
Other - Prefix:
Other - First Name:SLOAN
Other - Middle Name:CLARE
Other - Last Name:BYERS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:340 NE MAPLE
Mailing Address - Street 2:
Mailing Address - City:PULLMAN
Mailing Address - State:WA
Mailing Address - Zip Code:99163
Mailing Address - Country:US
Mailing Address - Phone:509-334-1133
Mailing Address - Fax:509-332-1608
Practice Address - Street 1:340 NE MAPLE
Practice Address - Street 2:
Practice Address - City:PULLMAN
Practice Address - State:WA
Practice Address - Zip Code:99163
Practice Address - Country:US
Practice Address - Phone:509-334-1133
Practice Address - Fax:509-332-1608
Is Sole Proprietor?:No
Enumeration Date:2008-04-10
Last Update Date:2014-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WALH00010921101YM0800X
MT1537101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT0000746510OtherBLUE CROSS-SHIELD OF MONTANA