Provider Demographics
NPI:1316203029
Name:FULLER LIFE INSTITUTE
Entity Type:Organization
Organization Name:FULLER LIFE INSTITUTE
Other - Org Name:FULLER LIFE FAMILY THERAPY INSITUTE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CLINICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:AMY
Authorized Official - Middle Name:
Authorized Official - Last Name:FULLER
Authorized Official - Suffix:
Authorized Official - Credentials:PHD, LMFT, LPC
Authorized Official - Phone:855-245-5433
Mailing Address - Street 1:4545 BISSONNET ST STE 289
Mailing Address - Street 2:
Mailing Address - City:BELLAIRE
Mailing Address - State:TX
Mailing Address - Zip Code:77401-3112
Mailing Address - Country:US
Mailing Address - Phone:855-245-5433
Mailing Address - Fax:855-245-5433
Practice Address - Street 1:4545 BISSONNET ST STE 289
Practice Address - Street 2:
Practice Address - City:BELLAIRE
Practice Address - State:TX
Practice Address - Zip Code:77401-3112
Practice Address - Country:US
Practice Address - Phone:855-245-5433
Practice Address - Fax:855-245-5433
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-04-06
Last Update Date:2012-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX201031106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Single Specialty