Provider Demographics
NPI:1578997615
Name:FULLITON, WILLIAM LESLIE (PHD)
Entity Type:Individual
Prefix:DR
First Name:WILLIAM
Middle Name:LESLIE
Last Name:FULLITON
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 1:1407 UNION AVE STE 1407
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38104-3680
Mailing Address - Country:US
Mailing Address - Phone:901-276-9606
Mailing Address - Fax:901-276-9607
Practice Address - Street 1:1407 UNION AVE STE 1407
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38104
Practice Address - Country:US
Practice Address - Phone:901-276-9606
Practice Address - Fax:901-276-9607
Is Sole Proprietor?:Yes
Enumeration Date:2013-08-26
Last Update Date:2019-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN1-17-26623103K00000X
TNP1531103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Multi-Specialty
No103K00000XBehavioral Health & Social Service ProvidersBehavior AnalystGroup - Multi-Specialty