Provider Demographics
NPI:1437325040
Name:FULLER PSYCHOLOGY CORPORATION
Entity Type:Organization
Organization Name:FULLER PSYCHOLOGY CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT, CLINICAL PSYCHOLOGIST
Authorized Official - Prefix:DR
Authorized Official - First Name:RUSSELL
Authorized Official - Middle Name:F
Authorized Official - Last Name:FULLER
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD
Authorized Official - Phone:858-558-7707
Mailing Address - Street 1:4225 EXECUTIVE SQ
Mailing Address - Street 2:SUITE 1110
Mailing Address - City:LA JOLLA
Mailing Address - State:CA
Mailing Address - Zip Code:92037-9122
Mailing Address - Country:US
Mailing Address - Phone:858-558-7707
Mailing Address - Fax:858-558-7708
Practice Address - Street 1:4225 EXECUTIVE SQ
Practice Address - Street 2:SUITE 1110
Practice Address - City:LA JOLLA
Practice Address - State:CA
Practice Address - Zip Code:92037-9122
Practice Address - Country:US
Practice Address - Phone:858-558-7707
Practice Address - Fax:858-558-7708
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-03
Last Update Date:2008-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY16530103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty