Provider Demographics
NPI:1326317264
Name:FULLER, JANICE
Entity Type:Individual
Prefix:
First Name:JANICE
Middle Name:
Last Name:FULLER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:159 WATERHOLE RD
Mailing Address - Street 2:
Mailing Address - City:COLCHESTER
Mailing Address - State:CT
Mailing Address - Zip Code:06415-2336
Mailing Address - Country:US
Mailing Address - Phone:860-267-8121
Mailing Address - Fax:
Practice Address - Street 1:159 WATERHOLE RD
Practice Address - Street 2:
Practice Address - City:COLCHESTER
Practice Address - State:CT
Practice Address - Zip Code:06415-2336
Practice Address - Country:US
Practice Address - Phone:860-267-8121
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-12-21
Last Update Date:2011-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst