Provider Demographics
NPI:1629120514
Name:FULLER, RIDGELY PLATER
Entity Type:Individual
Prefix:MS
First Name:RIDGELY
Middle Name:PLATER
Last Name:FULLER
Suffix:
Gender:F
Credentials:
Other - Prefix:MS
Other - First Name:RIDGELY
Other - Middle Name:PLATER
Other - Last Name:FULLER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LICSW
Mailing Address - Street 1:4 RIVERVIEW AVE
Mailing Address - Street 2:
Mailing Address - City:WALTHAM
Mailing Address - State:MA
Mailing Address - Zip Code:02453-3818
Mailing Address - Country:US
Mailing Address - Phone:781-790-1419
Mailing Address - Fax:
Practice Address - Street 1:4 RIVERVIEW AVE
Practice Address - Street 2:
Practice Address - City:WALTHAM
Practice Address - State:MA
Practice Address - Zip Code:02453-3818
Practice Address - Country:US
Practice Address - Phone:781-790-1419
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1003681041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical