Provider Demographics
NPI:1477737294
Name:FULLER, BRET EUGENE (PHD)
Entity Type:Individual
Prefix:
First Name:BRET
Middle Name:EUGENE
Last Name:FULLER
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:037 SW HAMILTON ST
Mailing Address - Street 2:STE 3
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97239-4096
Mailing Address - Country:US
Mailing Address - Phone:503-754-2634
Mailing Address - Fax:
Practice Address - Street 1:037 SW HAMILTON ST
Practice Address - Street 2:STE 3
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97239-4096
Practice Address - Country:US
Practice Address - Phone:503-220-8262
Practice Address - Fax:503-220-3499
Is Sole Proprietor?:Yes
Enumeration Date:2007-12-28
Last Update Date:2019-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR1839103TC1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling