Provider Demographics
NPI:1497806491
Name:FULLER, NANCY LOUISE (LICPSY)
Entity Type:Individual
Prefix:MS
First Name:NANCY
Middle Name:LOUISE
Last Name:FULLER
Suffix:
Gender:F
Credentials:LICPSY
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:175 WAMPUM ST
Mailing Address - Street 2:
Mailing Address - City:PLAINVILLE
Mailing Address - State:MA
Mailing Address - Zip Code:02762-1605
Mailing Address - Country:US
Mailing Address - Phone:508-695-8987
Mailing Address - Fax:
Practice Address - Street 1:275 NICHOLS RD
Practice Address - Street 2:
Practice Address - City:FITCHBURG
Practice Address - State:MA
Practice Address - Zip Code:01420-1919
Practice Address - Country:US
Practice Address - Phone:978-401-3970
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-16
Last Update Date:2019-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA11081103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical