Provider Demographics
NPI:1346420205
Name:FULLER, MEREDITH ANN
Entity Type:Individual
Prefix:DR
First Name:MEREDITH
Middle Name:ANN
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:PO BOX 350
Mailing Address - Street 2:
Mailing Address - City:WEST FALMOUTH
Mailing Address - State:MA
Mailing Address - Zip Code:02574-0350
Mailing Address - Country:US
Mailing Address - Phone:617-838-6035
Mailing Address - Fax:
Practice Address - Street 1:123 W CONCORD ST
Practice Address - Street 2:APT. 2
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02118-1507
Practice Address - Country:US
Practice Address - Phone:617-838-6035
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-11-08
Last Update Date:2007-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA7368103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAW05847OtherBCBS
MAW05847OtherBCBS