Provider Demographics
NPI:1689789901
Name:CHERYL C. FULLER PHD PA
Entity Type:Organization
Organization Name:CHERYL C. FULLER PHD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:CHERYL
Authorized Official - Middle Name:C
Authorized Official - Last Name:FULLER
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:817-735-8222
Mailing Address - Street 1:4320 BELLAIRE DR S APT 226W
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76109-5197
Mailing Address - Country:US
Mailing Address - Phone:817-735-8222
Mailing Address - Fax:817-924-1369
Practice Address - Street 1:1814 8TH AVE # B
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76110-1354
Practice Address - Country:US
Practice Address - Phone:817-735-8222
Practice Address - Fax:817-924-1369
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-19
Last Update Date:2010-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX2-3404103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX0012JCOtherBLUE CROSS BLUE SHIELD
TX00793ZMedicare PIN