Provider Demographics
NPI:1255476131
Name:FULLER, ADAM K (PHD)
Entity Type:Individual
Prefix:
First Name:ADAM
Middle Name:K
Last Name:FULLER
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:235 HAYDEN AVE
Mailing Address - Street 2:
Mailing Address - City:EVANSTON
Mailing Address - State:WY
Mailing Address - Zip Code:82930-5606
Mailing Address - Country:US
Mailing Address - Phone:435-631-9918
Mailing Address - Fax:
Practice Address - Street 1:191 OVERTHRUST RD
Practice Address - Street 2:
Practice Address - City:EVANSTON
Practice Address - State:WY
Practice Address - Zip Code:82930-9261
Practice Address - Country:US
Practice Address - Phone:435-631-9918
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-20
Last Update Date:2018-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY306103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY118774100Medicaid