Provider Demographics
NPI:1598705675
Name:FULLER, THOMAS CHARLES (PHD)
Entity Type:Individual
Prefix:DR
First Name:THOMAS
Middle Name:CHARLES
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 1:161 OTTAWA NW
Mailing Address - Street 2:STE 300C HUMAN RESOURCE ASSOCIATES
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49503
Mailing Address - Country:US
Mailing Address - Phone:616-458-0692
Mailing Address - Fax:616-458-8129
Practice Address - Street 1:2851 CHARLEVOIX DR SE STE 323
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49546-7092
Practice Address - Country:US
Practice Address - Phone:616-458-0692
Practice Address - Fax:616-458-8129
Is Sole Proprietor?:No
Enumeration Date:2006-06-07
Last Update Date:2023-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301006879103G00000X, 103T00000X, 103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
No103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
R67368Medicare UPIN
0D14603Medicare ID - Type Unspecified