Provider Demographics
NPI:1407312994
Name:FULLER, ROBERT
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:
Last Name:FULLER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16110 LOG ROW NW
Mailing Address - Street 2:
Mailing Address - City:MOUNT SAVAGE
Mailing Address - State:MD
Mailing Address - Zip Code:21545-1530
Mailing Address - Country:US
Mailing Address - Phone:301-268-7640
Mailing Address - Fax:
Practice Address - Street 1:39 E FRANKLIN ST
Practice Address - Street 2:
Practice Address - City:HAGERSTOWN
Practice Address - State:MD
Practice Address - Zip Code:21740-4914
Practice Address - Country:US
Practice Address - Phone:866-287-2306
Practice Address - Fax:888-244-1718
Is Sole Proprietor?:No
Enumeration Date:2019-02-20
Last Update Date:2019-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst