Provider Demographics
NPI:1538130984
Name:FULLER, MARY MARGARET (PHD)
Entity Type:Individual
Prefix:DR
First Name:MARY
Middle Name:MARGARET
Last Name:FULLER
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:40347 US HIGHWAY 19 N STE 103
Mailing Address - Street 2:
Mailing Address - City:TARPON SPRINGS
Mailing Address - State:FL
Mailing Address - Zip Code:34689-4841
Mailing Address - Country:US
Mailing Address - Phone:727-460-9834
Mailing Address - Fax:727-772-8212
Practice Address - Street 1:40347 US HIGHWAY 19 N STE 103
Practice Address - Street 2:
Practice Address - City:TARPON SPRINGS
Practice Address - State:FL
Practice Address - Zip Code:34689-4841
Practice Address - Country:US
Practice Address - Phone:727-330-8932
Practice Address - Fax:727-772-8212
Is Sole Proprietor?:No
Enumeration Date:2006-02-01
Last Update Date:2015-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLLMH 3125101YM0800X
103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst