Provider Demographics
NPI:1518054733
Name:JAMES W FULLER PHD INC
Entity Type:Organization
Organization Name:JAMES W FULLER PHD INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEP
Authorized Official - Prefix:DR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:WOODROW
Authorized Official - Last Name:FULLER
Authorized Official - Suffix:JR
Authorized Official - Credentials:PHD
Authorized Official - Phone:804-967-0486
Mailing Address - Street 1:2410 LARKWOOD ROAD
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:VA
Mailing Address - Zip Code:23294-4105
Mailing Address - Country:US
Mailing Address - Phone:804-967-0486
Mailing Address - Fax:
Practice Address - Street 1:5412 GLENSIDE DR STE B
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:VA
Practice Address - Zip Code:23228-3995
Practice Address - Country:US
Practice Address - Phone:804-967-0486
Practice Address - Fax:804-346-0066
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-08
Last Update Date:2008-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA09040005741041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAC08434Medicare PIN
VAR65539Medicare UPIN